T. Stübig

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs].

ZusammenfassungEinleitungFemurfrakturen stellen eine häufige Verletzung polytraumatisierter Patienten dar. Das Versorgungskonzept des Damage Control Orthopedics (DCO) konkurriert mit dem des Early Total Care (ETC).Material und MethodenIn einer retrospektiven Studie (2003–2007) wurden 73 polytraumatisierte Patienten mit Femurschaftfrakturen erfasst. Das Gesamtkollektiv wurde anhand der Verletzungsschwere (Injury Severity Score [ISS], 16–24 leicht, 25–39 mittelschwer, über 40 schwer) und des Versorgungskonzepts (DCO vs. ETC) unterteilt. Beim Vergleich der beiden unterschiedlichen Therapiekonzepte wurden klinische Daten und Kostenaspekte analysiert.ErgebnisseBeim leichten Polytrauma war die Dauer von Beatmung und Intensivaufenthalt in der DCO-Gruppe verlängert, die Gesamtkosten und die Kostenunterdeckung waren in der ETC-Gruppe erniedrigt. Beim mittelschweren Polytrauma zeigte sich in der DCO-Gruppe eine geringere Inzidenz von „adult respiratory distress syndrome“ (ARDS), die Kostenanalyse erbrachte in dieser ebenfalls eine höhere Kostenunterdeckung im Vergleich zur ETC-Gruppe.SchlussfolgerungBeim leichten Polytrauma scheint die Schere zwischen Kosten und Erlösen bei Behandlung nach dem ETC-Konzept weniger stark zu klaffen. Die Behandlungsstrategie sollte anhand des Verletzungsmusters festgelegt werden. Die Kosten sollten durch das Institut für das Entgeltsystem im Krankenhaus (INEK) entsprechend abgebildet werden.AbstractIntroductionFemoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC).Patients and methodsIn a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects.ResultsIn the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group.ConclusionFrom an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).INTRODUCTION Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Operative Behandlung der Achillessehnenruptur

The open tendon suture is the most commonly used method of treatment for Achilles tendon rupture in Germany. Over the last decade the therapeutic spectrum of operative methods has been further enlarged by the development of new minimally invasive surgical techniques. Important criteria for planning treatment are the location and age of the rupture and comorbidities. For recent Achilles tendon ruptures minimally invasive suturing is indicated but for older ruptures a reconstruction often has to be carried out. The decisive disadvantage of an open tendon suture is the relatively high risk of infection. Using minimally invasive surgical techniques the frequency of postoperative infection could be significantly reduced. The suture methods without opening the ruptured region can be collectively grouped under the term percutaneous suture techniques and the minimally invasive methods with opening of the rupture region as combined open percutaneous techniques. Documented problems with the Ma-Griffith technique, such as injury of the sural nerve, low stability of the suture and insufficient adaption of the tendon stumps have been minimized by new minimally invasive operation techniques. Achilles tendon ruptures which nearly always arise without any external influence or accidents can have substantial psychological consequences regarding the integrity of ones own body especially for people actively engaged in sport. This aspect should be considered and accepted in particular during postoperative treatment.

Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit Femurschaftfrakturen

ZusammenfassungEinleitungFemurfrakturen stellen eine häufige Verletzung polytraumatisierter Patienten dar. Das Versorgungskonzept des Damage Control Orthopedics (DCO) konkurriert mit dem des Early Total Care (ETC).Material und MethodenIn einer retrospektiven Studie (2003–2007) wurden 73 polytraumatisierte Patienten mit Femurschaftfrakturen erfasst. Das Gesamtkollektiv wurde anhand der Verletzungsschwere (Injury Severity Score [ISS], 16–24 leicht, 25–39 mittelschwer, über 40 schwer) und des Versorgungskonzepts (DCO vs. ETC) unterteilt. Beim Vergleich der beiden unterschiedlichen Therapiekonzepte wurden klinische Daten und Kostenaspekte analysiert.ErgebnisseBeim leichten Polytrauma war die Dauer von Beatmung und Intensivaufenthalt in der DCO-Gruppe verlängert, die Gesamtkosten und die Kostenunterdeckung waren in der ETC-Gruppe erniedrigt. Beim mittelschweren Polytrauma zeigte sich in der DCO-Gruppe eine geringere Inzidenz von „adult respiratory distress syndrome“ (ARDS), die Kostenanalyse erbrachte in dieser ebenfalls eine höhere Kostenunterdeckung im Vergleich zur ETC-Gruppe.SchlussfolgerungBeim leichten Polytrauma scheint die Schere zwischen Kosten und Erlösen bei Behandlung nach dem ETC-Konzept weniger stark zu klaffen. Die Behandlungsstrategie sollte anhand des Verletzungsmusters festgelegt werden. Die Kosten sollten durch das Institut für das Entgeltsystem im Krankenhaus (INEK) entsprechend abgebildet werden.AbstractIntroductionFemoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC).Patients and methodsIn a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects.ResultsIn the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group.ConclusionFrom an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).INTRODUCTION Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Surgical treatment of Achilles tendon rupture

The open tendon suture is the most commonly used method of treatment for Achilles tendon rupture in Germany. Over the last decade the therapeutic spectrum of operative methods has been further enlarged by the development of new minimally invasive surgical techniques. Important criteria for planning treatment are the location and age of the rupture and comorbidities. For recent Achilles tendon ruptures minimally invasive suturing is indicated but for older ruptures a reconstruction often has to be carried out. The decisive disadvantage of an open tendon suture is the relatively high risk of infection. Using minimally invasive surgical techniques the frequency of postoperative infection could be significantly reduced. The suture methods without opening the ruptured region can be collectively grouped under the term percutaneous suture techniques and the minimally invasive methods with opening of the rupture region as combined open percutaneous techniques. Documented problems with the Ma-Griffith technique, such as injury of the sural nerve, low stability of the suture and insufficient adaption of the tendon stumps have been minimized by new minimally invasive operation techniques. Achilles tendon ruptures which nearly always arise without any external influence or accidents can have substantial psychological consequences regarding the integrity of ones own body especially for people actively engaged in sport. This aspect should be considered and accepted in particular during postoperative treatment.

3D-fusionierte navigierte Anbohrung einer Osteonekrose des Femurkondylus

The primary goal of drilling procedures for the treatment of osteonecrotic lesions is revascularisation of the defect area. In the literature good results are reported for this technique in 70% of cases. Precise drilling of the necrosed area as part of a minimally invasive technique does, however, require unequivocal intraoperative identification of the region visually, either by arthroscopy or by fluoroscopy. In the case of inadequate imaging, as in our case, there is no longer any guarantee of precise drilling.Computer-assisted navigation system have already improved the precision of drilling procedures performed for various indications. Basically, however, a navigation is only as accurate as the underlying imaging. The use of preoperative data sets assumes an invasive and/or elaborate intraoperative recording procedure. For a procedure not requiring recording to be possible, image diffusion of the MRI and ISO-C(3D) data sets during the surgery would be necessary. In the present case a preoperative MRI data set was first combined with the ISO-C(3D) data set acquired intraoperatively. To this end, following application of the reference base a 3D scan was performed, and the data ascertained were transferred to the navigation system and in addition to the planning software. After fusion of the images the drilling canals were planned and implemented on the basis of the additional information emerging from the combination of the data. To be sure of success postoperatively, this was also merged with the preoperative MRI. The example shows that combining data sets makes it possible to improve the precision and safety of drilling in target areas that cannot be adequately imaged. In future, we hope it will prove possible to transfer the image data back into the navigation system after they have been merged. At present this is only possible with CT and MRI images. A comparative clinical trial is needed to find to what extent the success rate is improved over that achieved with conventional techniques.ZusammenfassungDas Ziel der operativen Therapie bei den Anbohrungen von Osteonekrosen besteht in der Revaskularisierung der Läsion. In der Literatur sind mit dieser Technik in 70% der Fälle gute Resultate beschrieben. Die exakte Anbohrung der Nekroseareale in minimal-invasiver Technik setzt jedoch die intraoperative eindeutige visuelle Identifizierung des Gebiets, entweder durch eine Arthroskopie oder die Fluoroskopie voraus. Bei unzureichender Darstellung wie in unserem Fall ist die präzise Bohrung nicht mehr gewährleistet.Mit dem Einsatz von Navigationssystemen konnte schon bei verschiedenen Indikationen die Präzision des Bohrungvorgangs erhöht werden. Prinzipiell kann die Navigation jedoch nur so genau sein, wie die zugrunde liegende Bildgebung. Die Verwendung von präoperativen Datensätzen setzt eine invasive bzw. aufwändige intraoperative Registrierung voraus. Um ein registrierungsfreies Vorgehen zu ermöglichen, wäre die Bildfusion der MRT- und ISO-C3D-Datensätze intraoperativ notwendig.Im Vorliegenden Fall wurde erstmals intraoperativ die Fusion eines präoperativen MRT-Datensatzes mit dem intraoperativ akquirierten ISO-C3D-Datensatzes durchgeführt. Hierzu wurde nach Anbringen der Referenzbase ein 3D-Scan durchgeführt, die akquirierten Daten wurden aufs Navigationssystem und zusätzlich auf eine Planungssoftware übertragen. Nach der Fusion der Bilder wurden die Bohrkanäle mit den zusätzlichen Informationen aus der Fusion geplant und durchgeführt. Um den postoperativen Erfolg zu sichern, wurde dieser ebenfalls mit dem präoperativen MRT fusioniert. Das Beispiel zeigt, dass durch Fusionierung von Datensätzen die Anbohrung von unzureichend darstellbaren Zielen, die Präzision und die Sicherheit erhöht werden kann. Kritisch zu betrachten ist, dass durch die Fusion ein zusätzlicher Zeitaufwand entsteht. In Zukunft ist es wünschenswert, dass nach Fusionierungen die Bilddaten zurück ins Navigationssystem übertragen können. Dies ist derzeit nur mit der CT- und MRT-Bildgebung möglich. Inwieweit wirklich eine Verbesserung der Erfolgsrate im Vergleich zu konventionellen Techniken resultiert, muss eine vergleichende klinische Studie zeigen.AbstractThe primary goal of drilling procedures for the treatment of osteonecrotic lesions is revascularisation of the defect area. In the literature good results are reported for this technique in 70% of cases. Precise drilling of the necrosed area as part of a minimally invasive technique does, however, require unequivocal intraoperative identification of the region visually, either by arthroscopy or by fluoroscopy. In the case of inadequate imaging, as in our case, there is no longer any guarantee of precise drilling.Computer-assisted navigation system have already improved the precision of drilling procedures performed for various indications. Basically, however, a navigation is only as accurate as the underlying imaging. The use of preoperative data sets assumes an invasive and/or elaborate intraoperative recording procedure. For a procedure not requiring recording to be possible, image diffusion of the MRI and ISO-C3D data sets during the surgery would be necessary.In the present case a preoperative MRI data set was first combined with the ISO-C3D data set acquired intraoperatively. To this end, following application of the reference base a 3D scan was performed, and the data ascertained were transferred to the navigation system and in addition to the planning software. After fusion of the images the drilling canals were planned and implemented on the basis of the additional information emerging from the combination of the data. To be sure of success postoperatively, this was also merged with the preoperative MRI. The example shows that combining data sets makes it possible to improve the precision and safety of drilling in target areas that cannot be adequately imaged. In future, we hope it will prove possible to transfer the image data back into the navigation system after they have been merged. At present this is only possible with CT and MRI images. A comparative clinical trial is needed to find to what extent the success rate is improved over that achieved with conventional techniques.

Drilling with 3D fluoroscopic navigation in osteonecrosis of the femoral condyle

The primary goal of drilling procedures for the treatment of osteonecrotic lesions is revascularisation of the defect area. In the literature good results are reported for this technique in 70% of cases. Precise drilling of the necrosed area as part of a minimally invasive technique does, however, require unequivocal intraoperative identification of the region visually, either by arthroscopy or by fluoroscopy. In the case of inadequate imaging, as in our case, there is no longer any guarantee of precise drilling.Computer-assisted navigation system have already improved the precision of drilling procedures performed for various indications. Basically, however, a navigation is only as accurate as the underlying imaging. The use of preoperative data sets assumes an invasive and/or elaborate intraoperative recording procedure. For a procedure not requiring recording to be possible, image diffusion of the MRI and ISO-C(3D) data sets during the surgery would be necessary. In the present case a preoperative MRI data set was first combined with the ISO-C(3D) data set acquired intraoperatively. To this end, following application of the reference base a 3D scan was performed, and the data ascertained were transferred to the navigation system and in addition to the planning software. After fusion of the images the drilling canals were planned and implemented on the basis of the additional information emerging from the combination of the data. To be sure of success postoperatively, this was also merged with the preoperative MRI. The example shows that combining data sets makes it possible to improve the precision and safety of drilling in target areas that cannot be adequately imaged. In future, we hope it will prove possible to transfer the image data back into the navigation system after they have been merged. At present this is only possible with CT and MRI images. A comparative clinical trial is needed to find to what extent the success rate is improved over that achieved with conventional techniques.ZusammenfassungDas Ziel der operativen Therapie bei den Anbohrungen von Osteonekrosen besteht in der Revaskularisierung der Läsion. In der Literatur sind mit dieser Technik in 70% der Fälle gute Resultate beschrieben. Die exakte Anbohrung der Nekroseareale in minimal-invasiver Technik setzt jedoch die intraoperative eindeutige visuelle Identifizierung des Gebiets, entweder durch eine Arthroskopie oder die Fluoroskopie voraus. Bei unzureichender Darstellung wie in unserem Fall ist die präzise Bohrung nicht mehr gewährleistet.Mit dem Einsatz von Navigationssystemen konnte schon bei verschiedenen Indikationen die Präzision des Bohrungvorgangs erhöht werden. Prinzipiell kann die Navigation jedoch nur so genau sein, wie die zugrunde liegende Bildgebung. Die Verwendung von präoperativen Datensätzen setzt eine invasive bzw. aufwändige intraoperative Registrierung voraus. Um ein registrierungsfreies Vorgehen zu ermöglichen, wäre die Bildfusion der MRT- und ISO-C3D-Datensätze intraoperativ notwendig.Im Vorliegenden Fall wurde erstmals intraoperativ die Fusion eines präoperativen MRT-Datensatzes mit dem intraoperativ akquirierten ISO-C3D-Datensatzes durchgeführt. Hierzu wurde nach Anbringen der Referenzbase ein 3D-Scan durchgeführt, die akquirierten Daten wurden aufs Navigationssystem und zusätzlich auf eine Planungssoftware übertragen. Nach der Fusion der Bilder wurden die Bohrkanäle mit den zusätzlichen Informationen aus der Fusion geplant und durchgeführt. Um den postoperativen Erfolg zu sichern, wurde dieser ebenfalls mit dem präoperativen MRT fusioniert. Das Beispiel zeigt, dass durch Fusionierung von Datensätzen die Anbohrung von unzureichend darstellbaren Zielen, die Präzision und die Sicherheit erhöht werden kann. Kritisch zu betrachten ist, dass durch die Fusion ein zusätzlicher Zeitaufwand entsteht. In Zukunft ist es wünschenswert, dass nach Fusionierungen die Bilddaten zurück ins Navigationssystem übertragen können. Dies ist derzeit nur mit der CT- und MRT-Bildgebung möglich. Inwieweit wirklich eine Verbesserung der Erfolgsrate im Vergleich zu konventionellen Techniken resultiert, muss eine vergleichende klinische Studie zeigen.AbstractThe primary goal of drilling procedures for the treatment of osteonecrotic lesions is revascularisation of the defect area. In the literature good results are reported for this technique in 70% of cases. Precise drilling of the necrosed area as part of a minimally invasive technique does, however, require unequivocal intraoperative identification of the region visually, either by arthroscopy or by fluoroscopy. In the case of inadequate imaging, as in our case, there is no longer any guarantee of precise drilling.Computer-assisted navigation system have already improved the precision of drilling procedures performed for various indications. Basically, however, a navigation is only as accurate as the underlying imaging. The use of preoperative data sets assumes an invasive and/or elaborate intraoperative recording procedure. For a procedure not requiring recording to be possible, image diffusion of the MRI and ISO-C3D data sets during the surgery would be necessary.In the present case a preoperative MRI data set was first combined with the ISO-C3D data set acquired intraoperatively. To this end, following application of the reference base a 3D scan was performed, and the data ascertained were transferred to the navigation system and in addition to the planning software. After fusion of the images the drilling canals were planned and implemented on the basis of the additional information emerging from the combination of the data. To be sure of success postoperatively, this was also merged with the preoperative MRI. The example shows that combining data sets makes it possible to improve the precision and safety of drilling in target areas that cannot be adequately imaged. In future, we hope it will prove possible to transfer the image data back into the navigation system after they have been merged. At present this is only possible with CT and MRI images. A comparative clinical trial is needed to find to what extent the success rate is improved over that achieved with conventional techniques.

Conservative functional treatment of Achilles tendon ruptures

The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.

Konservativ-funktionelle Behandlung der Achillessehnenruptur

The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.

Handling moderner Bildgebung in einem Hightech-Operationssaal

Operating rooms are the central unit in the hospital network in trauma centers. In this area, high costs but also high revenues are generated. Modern operating theater concepts as an integrated model have been offered by different companies since the early 2000s. Our hypothesis is that integrative concepts for operating rooms, in addition to improved operating room ergonomics, have the potential for measurable time and cost savings. In our clinic, an integrated operating room concept (I-Suite, Stryker, Duisburg) was implemented after analysis of the problems. In addition to the ceiling-mounted arrangement, the system includes an endoscopy unit, a navigation system, and a voice control system. In the first 6 months (9/2005 to 2/2006), 112 procedures were performed in the integrated operating room: 34 total knee arthroplasties, 12 endoscopic spine surgeries, and 66 inpatient arthroscopic procedures (28 shoulder and 38 knee reconstructions). The analysis showed a daily saving of 22-45 min, corresponding to 15-30% of the daily changeover times, calculated to account for potential savings in the internal cost allocation of 225-450 EUR. A commercial operating room concept was evaluated in a pilot phase in terms of hard data, including time and cost factors. Besides the described effects further savings might be achieved through the effective use of voice control and the benefit of the sterile handle on the navigation camera, since waiting times for an additional nurse are minimized. The time of the procedure of intraoperative imaging is also reduced due to the ceiling-mounted concept, as the C-arm can be moved freely in the operating theater without hindering cables. By these measures and ensuing improved efficiency, the initial high costs for the implementation of the system may be cushioned over time.

[Handling modern imaging procedures in a high-tech operating room].

Operating rooms are the central unit in the hospital network in trauma centers. In this area, high costs but also high revenues are generated. Modern operating theater concepts as an integrated model have been offered by different companies since the early 2000s. Our hypothesis is that integrative concepts for operating rooms, in addition to improved operating room ergonomics, have the potential for measurable time and cost savings. In our clinic, an integrated operating room concept (I-Suite, Stryker, Duisburg) was implemented after analysis of the problems. In addition to the ceiling-mounted arrangement, the system includes an endoscopy unit, a navigation system, and a voice control system. In the first 6 months (9/2005 to 2/2006), 112 procedures were performed in the integrated operating room: 34 total knee arthroplasties, 12 endoscopic spine surgeries, and 66 inpatient arthroscopic procedures (28 shoulder and 38 knee reconstructions). The analysis showed a daily saving of 22-45 min, corresponding to 15-30% of the daily changeover times, calculated to account for potential savings in the internal cost allocation of 225-450 EUR. A commercial operating room concept was evaluated in a pilot phase in terms of hard data, including time and cost factors. Besides the described effects further savings might be achieved through the effective use of voice control and the benefit of the sterile handle on the navigation camera, since waiting times for an additional nurse are minimized. The time of the procedure of intraoperative imaging is also reduced due to the ceiling-mounted concept, as the C-arm can be moved freely in the operating theater without hindering cables. By these measures and ensuing improved efficiency, the initial high costs for the implementation of the system may be cushioned over time.