Present trends in hospital management are facilitating the utilization of more accurate costing methods, which potentially results in superior cost-related information and improved managerial decision-making. However, the Activity-Based Costing method (ABC), which was designed for cost allocation purposes in the 1980s, is not widely used by healthcare organizations. This study analyzes costs related to selected categories of patients, those suffering from psoriasis, varicose ulcers, eczema and other conditions, within a dermatology department at a Czech regional hospital.The study was conducted in a hospital department where both inpatient and outpatient care are offered. Firstly, the diseases treated at the department were identified. Further costs were determined for each activity using ABC. The study utilized data from managerial and financial accounting, as well as data obtained through interviews with departmental staff. Using a defined cost-allocation procedure makes it possible to determine the cost of an individual patient with a given disease more accurately than via traditional costing procedures.The cost analysis focused on the differences between the costs related to individual patients within the selected diagnoses, variations between inpatient and outpatient treatments and the costs of activities performed by the dermatology department. Furthermore, comparing the costs identified through this approach and the revenue stemming from the health insurance system is an option.Activity-Based Costing is more accurate and relevant than the traditional costing method. The outputs of ABC provide an abundance of additional information for managers. The benefits of this research lie in its practically-tested outputs, resulting from calculating the costs of hospitalization, which could prove invaluable to persons involved in hospital management and decision-making. The study also defines the managerial implications of the performed cost analysis for the hospital management. Based on the analysis results, it is possible to standardize activities and performance appraisal (Benchmarking), and provide all necessary information for hospital budgeting practices, especially Activity-Based Budgeting (ABB). Hospitals worldwide struggle with the combination of limited resources, increasing costs and greater demand for services. Studies show evidence of a rise in healthcare costs in recent decades . Higher Many studies published in the past few decades have highlighted the ever greater importance of effective cost control and the necessity to apply advanced costing methods for more accurate analysis of the costs of providing services and handling patients within hospital organizations. The literature documents various methods used to estimate costs for patient-related services provided by hospitals. These include the use of average costs obtained from dividing total annual expenditure by patient throughput , the useThe objective of the study presented here was to perform a cost analysis of a selected sample of patients with different diagnoses by utilizing an advanced Activity-Based Costing system. It has already been proven that standard, simple costing methods, such as division or absorption costing, often provide inaccurate results in estimating the cost of individual patients of DRGs (diagnosis-related groups). Applying the more sophisticated Activity-Based Costing method (ABC) could improve the accuracy of the estimated costs. The additional information provided by ABC also benefits decision-makers and managers. This paper presents the manner of application of the ABC approach within the dermatology department of a Czech regional hospital. It also compares the costs of the selected sample of patients within the chosen diagnoses, as calculated by ABC, with the insurance payments received by the institution and the costs determined by the traditional costing methods currently used at the hospital.Approaches to estimating costs have been broadly divided into two categories: top-down and bottom-up . Top-dowProblems related to the use of traditional costing methods, which caused distortions in indirect costs, and accounting reports, had been excessively discussed in literature. These methods normally do not provide managerial interpretation and definition of tasks determining the control of deviations related to specific problems. Strong criticism of the traditional costing concept was voiced by Growing dissatisfaction with standard costing systems resulted in the creation of the Activity-Based Costing method, which was first introduced by One of the earliest studies focusing on applications of ABC in a hospital was published by Many authors describe the differences between traditional cost accounting and ABC accounting , but areThe general methodology for ABC implementation has been variously described. For example, ABC is related to the following terms - cost driver and cost object - and these basic concepts are discussed in many studies. According to It is uncertain why ABC has not been more commonly adopted by hospitals worldwide when the benefits of its adoption are so widely accepted by experts. Despite the benefits of ABC application, actual usage by healthcare organizations is scarce.  in the dermatology department of a Czech regional hospital. The following research questions were defined:What is the cost variability of the individual patients within the same DRG?What are the differences in the costs of patients receiving inpatient treatment compared to outpatient treatment?What are the differences between the costs of patients calculated by the Activity-Based Costing method compared to a traditional costing calculation and the insurance reimbursements received by the hospital?The hospital selected for cost analysis is a mid-size establishment, with 33 departments of primary care and 13 specialized centers, numbering 2,074 employees and 1,084 beds. The structure of the hospital includes 33 primary care cost centers and 32 support cost centers. The department selected (the Dermatology Department) is a medium-sized primary care department, generating an operating cost of approximately 0.6 mil EUR per year, and boasting personnel of 5 physicians, 13 nurses and 2 other staff. The majority of patients treated at the department consist of those with psoriasis, venous ulcers and eczematous and allergic skin diseases.Several data sources had been used for the study. Data related to the elementary cost elements was obtained from financial accounting reports. Additional cost data, related to the inter-organizational cost consumption, was obtained from additional management accounting evidence, which is performed additionally to the financial accounting evidence in order to register the consumption of services and related costs between the departments. Both information sources use different software tools.Another data source has been used for non-financial data. Different specialized data records were used for more accurate cost assignment. For instance, for the distribution of electricity or heating costs we used the specialized evidence kept by the maintenance department.Non-financial data related to the resource and activity cost drivers was obtained partly from the patient registry and partly from interviews with department employees. Data related to the individual patient and their consumption of activity units was obtained mostly from the patient registry.Based on interviews with the senior doctor and his assumptions, we expected the following results from the research questions. According to the observed relevant differences between the length of stay and consumption of medications and material between individual patients with the same diagnosis, we expected also relevant differences in cost. Medical practices in recent decades also mostly favor outpatient treatment. The objective of the study was then also to verify this assumption and investigate the “profitability” of inpatient and outpatient treatments in comparison to the costs and revenues of selected patients. We expected also relevant differences between the cost calculated by the ABC method and traditional costing recently used within the department.This study includes several ethical considerations. The traditional managerial outputs of the ABC system include the use of more accurate cost data for better profitability management and cost optimization. This means that more accurate cost information in comparison with the price of the product (reimbursement) allows the manager to focus on the more profitable products or customers. The ABC approach also allows a better analysis or relations between the consumed costs and performed activities, which could lead to a reduction of ineffective tasks and could identify inappropriate costs. The effective adoption of such actions within healthcare organizations is mostly limited by ethical reasons.In order to calculate the cost of an individual patient it was first necessary to apply the five consequent steps of the ABC application. The first of these was to process the financial data to make it usable for the ABC method. Direct and indirect costs registered in the department cost center were distinguished. Direct costs, e.g., the medicines prescribed or materials used for individual patients, were allocated directly to the pursued object. Indirect (overhead) costs were allocated through the activities discerned.The next part of the implementation process was to define the major activities that take place in the department. Consequently, it was necessary to discern those that reflect the significant cost activities of the department. The entire ABC system would be more complex and less clear if too many activities were identified for the department. In this case, the department identified a total of 11 primary activities, making it relatively low in volume compared with other ABC implementations presented, but seemingly sufficient for accurate cost allocation. An overview is shown below:◾Outpatient examination◾Specialized examination - Dermatoscope◾Photo-balneo-therapy◾Instrumentation massage - Pneuven◾Minor surgical procedures◾Patient admission◾Hospitalization◾Treatment of psoriasis◾Treatment of varicose ulcers◾Treatment of eczema and other illnesses◾Patient releaseThe primary activities were provided by the Dermatology Department and by selected primary care cost centers, like the surgery department. In order to assign the full cost of individual primary activities, subsequent secondary (infrastructure) activities were identified:◾Management and administration◾Human resources management◾Information systems and technology◾Facility management◾Medical support servicesSupport activities represent those provided by the support cost centers.After identifying the main activities, indirect costs were allocated to them. A different allocation mechanism was utilized for each cost element. Several resource cost drivers were defined, e.g., labor (considered as consumption) by physicians, and quantified by activities, the square meters of the floor space related to activities, etc. All costs were assigned to activities using an Activity Cost Matrix, which displays the relations between the given indirect cost and the activities.Total cost of primary activities shows Similarly, the cost of secondary activities was calculated. In this instance, the cost allocation process was much simpler, as only 5 support activities across the entire establishment were identified, and the costs from all the support cost centers were assigned to such support activities.It was also necessary to determine the amount of costs relating to support activities within the hospital. Another requirement was to quantify the costs of individual centers and divide them into the consequent support activities. It was then necessary to assign a specific portion of these costs to the Dermatology Department. Regarding the activities of management and administration, IS/IT and facility management, the costs of these activities were estimated for the Dermatology Department. The costs were calculated in accordance with the cost of the Dermatology Department in relation to the total cost (the ratio is 0.97%). The costs of human resources management were transposed by the employees of the Dermatology.Department to the total number of employees - the share is, consequently, 1.02%. The activity labeled “Medical support services includes the various activities performed by the special departments whose outputs are consumed by other primary care departments, i.e. Imaging Methods , the Department of Clinical Biochemistry, the Department of Medical Microbiology, the Blood Transfusion Department, Nuclear Medicine, the Allergy and Clinical Immunology Laboratory, and the Department of Anatomical Pathology.A list of these departments is presented in The total activity cost shows the cost of activities, including the allocated cost of secondary activities.The next step of the cost calculation process was to calculate activity rates, i.e., activity unit costs. In order to calculate such activity rates it is necessary to perform several steps. Firstly, the cost drivers for each activity had to be determined. We used, for example, the number of examinations, patients, the quantity of patient days and number of hours. Secondly, the output measures for individual activities were identified. The output measure determines the volume of the activity in the period observed. All data were registered in the hospital’s information systems. After gathering the required data, the activity rates had been calculated by the division of total activity cost by the activity output measure estimated. The final part of cost calculation requires allocating an activity cost to an individual cost object. The ABC system implemented was designed so as to calculate the cost of an individual patient or hospitalization case as the cost object. In order to assign the cost to a cost object, one needs to identify the volumes of individual activity outputs consumed by a specific patient. Final assignation of the cost expended to the specific cost object allows for calculating the total cost per individual patient. After developing the cost allocation methodology, which adheres to Activity-Based Costing principles and facilitates more accurate cost allocation, a cost analysis of selected patient groups was performed. The patients were divided into three major groups according to the relevant DRG: psoriasis, varicose ulcers and eczema and other illnesses. The objective of the cost analysis was to compare the ABC cost of patients within the defined patient groups and correlate the inpatient and outpatient treatment of the defined DRGs. In order to analyze the cost of patients, a sample of 10 outpatients and 15 inpatients was evaluated.methods part of the study. It can be seen that the costs range from 219.84 € to 1,370.44 €. Patient 4 generated a very low cost in comparison with the others, the reason being that he was hospitalized for a shorter time and therefore did not consume activities as widely as other patients. The costs are mainly influenced by the length of hospitalization and other treatments received, such as in the case of photo-balneo-therapy for psoriasis. Psoriasis represents a single DRG payment in the amount of 641.38 €. For comparison, the last column presents costs as calculated by KNTB itself. It can be seen that the diameter does not differ significantly, but the actual calculation of the costs to the patient are within +/- 15%. The table below provides data on the minimum, median and maximum values. It is also an important indicator of the level to which funds match up to health insurance payouts. In this case, the average cost per ABC is higher than the average reimbursement from the insurance companies (approximately 73%).Initially, analysis was conducted on the patients with psoriasis. 15 hospitalized individuals and 10 outpatients with psoriasis were chosen. A second analysis was carried out for patients suffering from varicose ulcers. Similarly, as for psoriasis patients, 15 hospitalized patients and 10 outpatients with varicose ulcers were chosen for analysis. A final analysis was made for eczema and other illnesses. Similarly, 15 hospitalized individuals and 10 outpatients were chosen for analysis. The performed cost analysis led to several important results and implications for management. Firstly, the study confirmed the expected result, i.e., that the cost of individual patients within the selected diagnoses is diverse. Cost diversity is caused by the differences in the activity outputs consumed by the individual patients. Another important implication arises through comparing the costs calculated by ABC and the reimbursements received. Such reimbursements for hospitalization treatment are, under present conditions in the Czech Republic, arrived at through a fixed payment for the relevant DRG. Cost analysis showed that the average costs of these patients are only partially covered by such reimbursements. Nevertheless, reimbursements paid out for outpatient treatment are worked out according to the direct payment per task defined. In this case, average reimbursement payouts are higher than the costs calculated by ABC. This means that the yield from outpatient activities goes towards covering the costs of hospitalization. The department could then improve cost efficiency through changing the type of treatment offered from hospitalization to outpatient care. This could lead to reduced expenditures and increased reimbursements from the insurance companies.Additionally, interesting results were found through comparing the ABC cost calculated via the newly designed ABC system and traditional cost calculations, as based on a fixed daily rate per patient day and the individual evaluation of the several direct activities chosen. The group of patients with psoriasis showed little difference between the cost calculated via ABC and the traditional approach. This is due to the relatively standardized manner of treatment given. However, for varicose ulcer patients, the variations between the ABC and traditionally-calculated costs could prove important in terms of diagnoses, where sizeable differences exist between patients. This means that the way in which individual patients are treated may well vary. In the case of diagnoses where treatment is performed in a more standardized way and hence the difference in the treatment received by individual patients is not important, both costing methods arrive at similar results.Using the ABC system to calculate the cost of patients and consequent cost analysis brings with it several major benefits. The ABC method could be considered as more accurate and relevant than the traditional costing method. Greater accuracy results from the better detailed structure of the cost pools - the activities and wider variety in the forms of cost drivers. The outputs of ABC costing could potentially create an abundance of additional information for managers. For instance, they would be able to analyze the total cost of activities, analyze the output of the activities, measure the level of utilization of individual activities, and measure the impact on the cost of a patient. Reaching a sufficient level of utilization could prove important in instances of costly attempts at treatment using, e.g., highly expensive equipment.Despite the increased accuracy of the ABC system developed, many reasons still prevail as to why the costing method utilized herein might not be considered as one of absolute accuracy. Allotting an overhead cost is always based on a specific proportion of arbitrary allocation. According to the nature of the overhead cost, we do not have any real way to verify the accuracy of the cost allocation process. Based on theory, we expect higher accuracy from the ABC system, but a poorly-designed system could in some cases lead to more inaccurate cost assignments than with the traditional costing approach. A major limitation of the model presented is in allocating the costs of medical support services. Despite the fact that we conducted a detailed analysis of costs related to the Dermatology Department, further allocation to the individual patient was arrived at via an arbitrary principle. Inaccurate allocation of the medical support services could distort the final cost calculation. However, this issue might be solved relatively easily by transposing such medical support services into a standard activity structure. Nevertheless, this would add greatly to the complexity of the system as it results in dramatically increasing the number of activities at the very least. Having said this, the cost of medical support services allocated to the Dermatology Department was only 8% of the total cost.Another important limitation of the presented study is the time and resource requirements for the data processing. It is an accepted fact that using the ABC method is much more demanding in terms of data than a traditional cost evaluation. Applying the costing system at the Dermatology Department took one month to implement. The present study includes the ABC model, which is relatively simple in comparison with other ABC healthcare models in number of activities and used cost drivers. The most time-consuming step was allotting the cost registered in the accounting system to the defined structure of activities. It was also necessary to acquire additional data from the various departments related to accurate overhead cost allocation, such as the proportion of energy consumption related to individual departments, etc. Acquiring other additional data from the system of patient evidence was also necessary. However, once such an ABC system is implemented, and the relations between the costs, activities and cost objects are established in the costing system, its future operation is more simple. Furthermore, due to the high quality of data evidenced on the individual patients, it could be automated relatively easily.A correctly implemented ABC system offers a good alternative to traditional costing, allowing for greater accuracy that would in turn provide a more precise cost analysis. Nevertheless, it would be necessary to avoid the excessive structure of the ABC model, which could lead to data overload.methods sections, the managerial implications of the performed study is more limited in comparison with business organizations. A hospital organization could not so easily manage the portfolio of the customers/patients. Also, the simple methods of cost reduction based on the study of relationships between the consumed costs and activities and identification of inappropriate costs could be not so easily performed like in the case of business organizations due to the crucial focus on treatment failures or errors.As mentioned in the The most important benefit of the system herein described is the ability to calculate more accurately the cost of an individual patient. The method highlights differences between the costs of an individual patient under the same diagnosis and their differing demands on hospital activities. Traditional costing systems mostly determine average costs, failing to note any differences between individual patients. If one lacks information on such cost differences, one is unable to analyze the causes of those differences. Calculating a more accurate cost of an individual patient may also result in “profitability” or verifying the cost coverage of patients or the diagnosis types presented in the study. Comparing the calculated cost and revenue (reimbursement) for an individual patient enables the user to discern types of patient with a diagnosis that could financially benefit the hospital, as well as those for which the expenditure required would not be covered. As can be seen, many diagnoses result in a low amount of reimbursement, which has a crucial impact on the profitability of a healthcare organization. Identifying the DRGs of patient types of low profit could lead to appropriate managerial decisions.


This paper proposes a new automatic and adaptive aircraft target detection algorithm in high-resolution synthetic aperture radar (SAR) images of airport. The proposed method is based on gradient textural saliency map under the contextual cues of apron area. Firstly, the candidate regions with the possible existence of airport are detected from the apron area. Secondly, directional local gradient distribution detector is used to obtain a gradient textural saliency map in the favor of the candidate regions. In addition, the final targets will be detected by segmenting the saliency map using CFAR-type algorithm. The real high-resolution airborne SAR image data is used to verify the proposed algorithm. The results demonstrate that this algorithm can detect aircraft targets quickly and accurately, and decrease the false alarm rate. The ability to provide high resolution images of synthetic aperture radar (SAR) in any weather and at any time is extremely important for disaster monitoring, modern military reconnaissance and combat tasks. However, the special characteristics of SAR imaging process, speckle noise, and the high-variability of man-made targets due to the change of azimuth, imaging parameters, shade, background environment and so on, lead to a huge challenge in the SAR image target detection field ,2. ThereTarget detection in a SAR image involves namely extracting the targets of interest from a scene with a background which usually is contaminated by heavy noise. This problem has been studied by many researchers until now. Based on the analysis of , the metet al. [et al. [For the single-feature based category in which only brightness feature is utilized, the Constant False Alarm Rate (CFAR)-based methods are widely exploited in the literature because the CFAR methods have the properties of simple computing, constant false alarm, adaptive threshold, and fast speed of extracting targets from the complex background ,6,7. CFAet al.  extracts [et al.  presenteet al. proposed a detection algorithm based on visual saliency [et al. proposed a vehicle target detection algorithm with SAR images based on contextual knowledge [i.e., terrain types, distances to boundary and target aggregation degree) and the result of Markov Random Field (MRF) based segmentation as the initial guess for improved CA-CFAR. These algorithms perform well in particular situation when the targets are small and not separated into many blobs.For the multi-feature based category, the algorithms try to extract additional features, such as variance features, fractal features, and wavelet features ,20. As tsaliency . Howevernowledge . It combIn our application case of aircraft detection from high-resolution SAR image, some special properties should be taken into account. First, an airplane target consists of bright pixels caused by strong scattering points and dark pixels generated by weak scattering points in some places of the target. This property indicates that we can extract the candidate regions as the potential target location according to brightness. Then we may segment the intact target by grouping the bright and dark pixels of a target in the local candidate region. As mentioned above, it is hard to group the broken parts of aircraft to an intact one if we only segment the pixels separately in SAR image. However, these dark and bright pixels form a special feature of salient structure texture, which can be exploited to perceptually connect the target blobs. Second, the contextual information that the aircraft targets always park on the apron area can be utilized so that we only need to detect the aircraft targets in candidate apron region. Because segmentation of apron region in high resolution SAR image is comparatively easy job, the utilization of contextual knowledge is very critical to reduce false alarm rate and computational complexity.et al. proposed local edge distributions (LED) for detection of salient structure textures [et al. [Visual saliency is the noticeable perceptual property which makes the targets in the visual field pop out and catches our attention. In the computer vision field, a lot of works were conducted on detecting targets by analyzing the saliency map in image. As the core part of such work, the measurement of saliency is very crucial, which tells us which part of an image is salient. For remote sensing application, Hu textures . Motivat [et al.  to exploContextual cue is integrated into the algorithm. Apron regions where the airplanes park are generally dark homogenous so that they are easily extracted from the whole image of airport.et al. [The concept of gradient textural saliency map is introduced. As analyzed by Hu et al. , each taDirectional local gradient distribution is proposed to measure the textural saliency of a target, which we call as GTS. The saliency of each pixel is represented by an index which is computed by local gradient point density in a local window. This method is able to connect the dark and bright pixels of a target by imposing the interactive constraints between the neighboring pixels.Therefore, the proposed aircraft detection algorithm consists of four steps: (1) extracts the apron areas using segmentation; (2) generates gradient image in apron areas; (3) produce gradient textural saliency map with directional local gradient distribution algorithm in the candidate regions; (4) use a more precise method—TL-CFAR to detect aircraft target from the saliency map. As a whole, the novelties of the algorithm include the following aspects:The remainder of this paper is organized as follows. et al. proposed local edge distributions for detection of salient structure textures for optical remote sensing image [et al. also presented a detection algorithm in SAR image motivated by the idea of visual saliency [Since a SAR image is the sampling of the backscattering coefficient, CFAR-based algorithms are naturally adopted to determine if a pixel belongs to a target in terms of statistical computation. These methods output isolated discriminative results without considering the relationship of neighboring pixels in a target. Thus, the targets extracted by CFAR-based methods must be processed further by clustering or morphological steps in order to prepare intact objects for recognition. However it is not easy to get this job done because of the loss of much original information. In the computer vision field, salient object detection is becoming one of the mainstream generic object detection methods ,25. The ng image . The algsaliency . HoweverBefore we present the details of our algorithm, we first explain the concept of gradient textural saliency map. As we know, our attention to an object in the visual field is just because the object is significantly distinct from the surroundings, which is called as visual saliency defined in contrast based on various types of image features. For optical images, there are a lot of definitions of contrast measures to create different visual saliency maps . Few worThe targets in SAR images consist of strong scattering spots, which may emerge as several pixels. Normally, an airplane target is not as intact as the appearance shown in the optical image. The bright pixels can be perceived as part of an airplane just because the fragments of the target have visual saliency. However, taking the texture of SAR image into account, we can segment the enclosed target region even though there are holes and clearance among the target fragments. Specifically, the texture feature in gradient domain of a target in SAR image makes target region salient from the background. Following the framework of salient object detection ,25, the Even though SAR image is not genuine optical image, the neighboring pixels still have close connections such as similar brightness or gradient. To utilize this locality, we define textural saliency of a pixel as an index computed in the gradient domain in a local window. Specifically, the textural saliency index of a pixel is defined on the basis of the gradient distribution in the local window. In order to make the distribution representative and avoid the impact of noise, we choose a local 4-direction window with interval of 90° between the two neighboring directions, shown as From As shown as m × n, the computation formulas are shown in the following [With the preprocessed image by using divided linear stretch and Frost filter to suppress the speckle noise, we extract the horizontal and vertical gradient of the image by differential mean value based on the two neighbors of a pixel firstly. Then, we compute the magnitude of all the pixels by the horizontal and vertical gradient. For a SAR image with size of ollowing :(1)G; else, set its index as zero.However, we cannot see the targets in the original gradient textural saliency map because the pixel values of the original saliency map are very small. Here we use mean-variance gray scale normalization method to normalize the gray scale to enhance the saliency map. The normalization formula is shown as following:This method can preserve precise and rich structural and textual feature of the aircraft target, and it can also keep the whole object intact to the greatest extent. These properties make this method have a great advantage in SAR aircraft detection. An example of the generation of the normalized saliency map is shown in In this paper, we use TL-CFAR to segment the gradient textural saliency map to get a more precise result, because TL-CFAR detection algorithm considers both the background distribution and the local structural of the targets. The segmentation example is shown as Until now, CFAR detectors are commonly used methods for detecting the targets in SAR image. Thus, we adopt the CFAR-type detector to extract the airplane targets from the produced textural saliency map. As described in the last section, we can locate the apron area firstly, and then we extract the candidate regions where the saliency indexes are calculated. The context information of apron and the candidate regions are important for accuracy and computational complexity of detection. In general, the entire aircraft detection procedure in high-resolution SAR images is illustrated in Details of the steps are shown in the following:(1)Enhance SAR image and remove image noise;(2)Extract apron and non-apron area from the preprocessed image. In this step, we can obtain an apron area map and a map of candidate regions on the apron area;(3)Obtain the original gradient image of the image by computing the horizontal and vertical gradient amplitude;(4)Apply directional local gradient distribution over apron and candidate regions to compute the gradient textural saliency map;(5)Segment the gradient textural saliency map with TL-CFAR algorithm. Finally, we detect the aircrafts located on the apron.The hardware environment of the experiments is the AMD Athlon(tm) Π X4 631 Quad-Core Processor 2.60 GHz, 4 GB of RAM; the software development environment is Microsoft Visual C++ 6.0 in Windows 7 of 32-bit operating system. In the experiments, we use real-world X-band airborne SAR images provided by Beijing Institute of Mechanical and Electronics Engineering, and the resolution for both range and azimuth is 0.5 m. All of them are the magnitude-detected images converted from the single-look complex-valued SAR images. In addition, the detectors for comparison are: VI-CFAR , SCCA-CFtrue positive rate (TPR) and false positive rate (FPR) as:For quantitatively evaluating the performance of a detector, the receiver operator characteristic curve (ROC curve) is usually adopted. Given a threshold for a detector, the pixel number of true positive (TP) is calculated by comparing the detection target with the ground truth mask, and the pixel number of false positive (FP) is calculated similarly. Suppose the pixel number of the ground truth mask is GTP, then we can compute vs. FPR.Furthermore, the ROC curve is plotted with the pairs of TPR For the final evaluation of detectors, we draw the ground truth of airplane targets in the original SAR images. Different local 4-direction windows produce different detection results. For discrete image, here we compare two kinds of local window, one is with four direction of 45°, 135°, 225°, 315° and the other is 0°, 90°, 180°, 270°. In addition, window’s radius is 8 pixels for this experiment. In order to determine the best one between the two directions, we draw the ROC curve to reveal the performance. From the quantitative comparison demonstrated in From From Equation (2), we can see that the value of the gradient textural saliency index is determined by From On the other hand, the different radius of local 4-direction window has different impact on the final detection result. The determination of radius can be considered from two aspects: quantitatively and qualitatively. For the quantitative determination, we draw the ROC curve for different radius, which is illustrated as To give an intuitive explanation, the airplane detection results by using different window radius are shown as From the quantitative and qualitative comparison results, we set the radius 8 pixels in the following experiments.In this section, we compare the performance of the detectors quantitatively using ROC curves. In order to show the detected result intuitively, we compare the detected target for different detectors in three cases: multiple targets existing in apron, one target existing in apron and non target case.In order to compare the performance of different detector objectively, we draw the ROC curves for different detectors by varying their detecting parameters. The ROC curves are shown as Among the five detectors, GTS and LED are superior than the other algorithm. Overall, the GTS achieves the best performance among the five detectors, which demonstrates the performance advantage of our proposed GTS detector.In the following parts, we will visually analyze the performance of structure retention and object integrity for different detectors including the GTS-based detector in three cases: multi-targets, one-target and non-target situation.Before we detect the targets, we apply the Frost filter to suppress the speckle noise on the original image, the width of the sliding window, the attenuation factor and the standard deviation of noise of the Frost filter are respectively 5 pixels, 5, and 0.5 in our experiment as empirical value. The original SAR images which contain multiple aircraft targets is shown as rding to . BesidesThe results of different detectors under the same apron are shown in Except for the practical visual results of all the detectors, we also can look over the results in terms of quantitative analysis. As can be seen, GTS has the biggest TPR, and SCCA-CSAR has the biggest FPR. The numerical values can be combined with the visual results appearing in We can conclude from To conclude, GTS-based detector can keep the parts of an aircraft combine tight enough, keep a target uniform fully connected and meanwhile keep the false alarm rate in a tolerable allowance. The parameters here are set same as the multi-target case. The results of different detectors are shown in In this part, we will analyze the performance of different detectors under non-target situation. The parameters here are set same as multi-target case. The results of different detectors are shown in From In this paper, we proposed an aircraft detection algorithm in high-resolution SAR images based on gradient textural saliency map and contextual cues. The contextual cues that aircraft locates in apron and appears as a hole when detecting apron, can largely reduce the computational complexity because we can analyze gradient textural saliency map only in the local area indicated by the hole. In addition, the algorithm obtains much more precise and intact information of the aircraft targets compared with the other algorithms. The experimental results based on the real SAR images have validated that the proposed GTS-based algorithm is effective and practicable.As the front-end input for the automatic target recognition (ATR) system, the improvement of detection accuracy to overcome the discontinuity of target in SAR image needs to be further studied. The strategies include developing new feature descriptor of target, constructing new model of contextual knowledge, and exploiting the distribution distinction between target and background clutter. For practical application, the optimization of detection algorithms to satisfy the computational constraints on running time, memory capacity and configuration of embedding system is also a big challenge.


Computerized decision support systems (CDSSs) are information technology-based software that provide health professionals with actionable, patient-specific recommendations or guidelines for disease diagnosis, treatment, and management at the point-of-care. These messages are intelligently filtered to enhance the health and clinical care of patients. CDSSs may be integrated with patient electronic health records (EHRs) and evidence-based knowledge.We designed a pragmatic randomized controlled trial to evaluate the effectiveness of patient-specific, evidence-based reminders generated at the point-of-care by a multi-specialty decision support system on clinical practice and the quality of care. We will include all the patients admitted to the internal medicine department of one large general hospital. The primary outcome is the rate at which medical problems, which are detected by the decision support software and reported through the reminders, are resolved . Secondary outcomes are resolution rates for reminders specific to venous thromboembolism (VTE) prevention, in-hospital all causes and VTE-related mortality, and the length of hospital stay during the study period.The adoption of CDSSs is likely to increase across healthcare systems due to growing concerns about the quality of medical care and discrepancy between real and ideal practice, continuous demands for a meaningful use of health information technology, and the increasing use of and familiarity with advanced technology among new generations of physicians. The results of our study will contribute to the current understanding of the effectiveness of CDSSs in primary care and hospital settings, thereby informing future research and healthcare policy questions related to the feasibility and value of CDSS use in healthcare systems. This trial is seconded by a specialty trial randomizing patients in an oncology setting (ONCO-CODES).https://clinicaltrials.gov/ct2/show/NCT02577198?term=NCT02577198&rank=1ClinicalTrials.gov,  Despite the proliferation of clinical guidelines and continued efforts by local and national healthcare systems to optimize decision-making on patient diagnosis, treatment, and management, the quality of medical care is variable and often suboptimal . There rComputerized decision support systems (CDSSs) are information technology-based software that provide health professionals with actionable, patient-specific recommendations or guidelines for clinical care at the point-of-care; these messages are intelligently filtered and presented at appropriate times during the decision-making process in order to enhance patients’ health , 5. The In particular, studies focusing on the effectiveness of “new generation” CDSSs demonstrate their potential to assist with problems raised in clinical practice, decrease the rate of medication errors, increase clinicians’ adherence to guideline- or protocol-based care, and, ultimately, improve the overall efficiency and quality of healthcare delivery systems –19. ThesThis has led to some early work: a systematic review assessing the effectiveness of such new generation CDSSs demonstrated encouraging results . AlthougCurrent research on CDSSs suffers two noteworthy limitations . First, Our study aims to evaluate the effectiveness of patient-specific, point-of-care reminders generated by the Medilogy Decision Support System (MediDSS)  on cliniThis protocol is reported in accordance with the SPIRIT 2013 guidance for content of clinical trial protocols , 25.The CODES (computerized decision support) trial will implement a pragmatic, parallel group and randomized controlled design with a 1:1 allocation ratio. The flow diagram of the study can be found in Fig. The study will involve the medical staff of the internal medicine departments of the Vimercate Hospital from Azienda Ospedaliera di Desio e Vimercate (AODV) a multi-site hospital system located in the Lombardy region of Italy . AODV inSince 2010, the Vimercate Hospital has been electronically tracking all clinical and administrative information through an EHR system based on the “Tabula Clinica” platform  .As a pragmatic clinical trial , 29, CODWe selected the MediDSS after a comparative assessment of available editorial products using a predefined set of essential criteria , 31. Medn = 262) that cover a large number of health conditions across specialties and are derived from the EBMeDS and SFINX database. In addition, 17 local reminders have been carefully selected by a team of doctors at Vimercate Hospital, along with members of the trial team. Table MediDSS may be used as a stand-alone application, or may integrate structured patient data from EHR to generate patient-specific reminders, therapeutic suggestions, and diagnosis-specific links to full-text guidelines. Reminders are automatically generated and displayed on the monitors of clinicians when they open a patient’s EHR, enter a new diagnosis, prescribe a drug, or when new laboratory test results are available. Reminders were formed using international evidence-based guidelines and subsequently approved by an international panel of experts. Our study will use international reminders n = 62 that cMediDSS reminders will be shown on the EHR of patients only within the intervention group. During the care of control group patients, the generated reminders will not be shown to the physicians, such that the control is usual clinical practice without the use of the MediDSS service. However, physicians in both groups will have access to the best evidence for usual care at all times during the trial through the active searching of full-text EBM guidelines on the Internet. All participating physicians will be informed on the availability and use of the MediDSS system.The intervention is a new technology: its integration in the current hospital system requires the configuration and customization of the software. To allow security controls and successful implementation, the CDSS will be sequentially rolled out to participants over a number of time periods. We anticipate that the number of periods will be limited . Over an initial period, all participants will receive the intervention. The order in which participants will receive the intervention is not determined at random, but will be determined by selecting physicians prone to provide constructive feedback to the implementation team. The RCT adopts a stepped wedge implementation of the intervention, but not a stepped wedge design . Sequent(i)Despite evidence supporting the benefits of VTE prophylaxis based on the risk stratification process  as well (ii)The Vimercate Hospital has an increasingly large population of elderly (aged >65 years) and very elderly (aged >80 years) subjects, who have a higher risk of recurrent VTE and acute pulmonary embolism .(iii)Between 2010 and 2012, 45 patients  and 75 patients  died, respectively, within 30 and 90 days after discharge due to VTE .(iv)Research has shown the use of CDSSs to improve the assessment of patients’ risk for VTE, facilitate appropriate administration of prophylaxis interventions, and reduce the rate of symptomatic VTE in hospitalized patients –53.In order to encourage the participation of the hospital staff within the study, we invited hospital representatives to assess the priority needs of the hospital wards and develop a set of reminders to address them. One topic of particular interest to the hospitals involved venous thromboembolism (VTE) prevention. The rationale for the prioritization of this condition is provided below:In order to develop the set of reminders for VTE prevention, the local hospital expert group proposed a risk stratification process based on the Padua score . This foAdjusting warfarin dose in atrial fibrillationAlert on heparin-induced thrombocytopeniaClopidogrel, prasugrel or ticagrelor, and aspirin in acute ST-segment elevation myocardial infarction (STEMI)Low-molecular-weight heparin as anticoagulant for patients with VTE and cancerSelection of antithrombotic therapy in atrial fibrillation on the basis of the CHA2DS2VASc scoreSupplementary laboratory measurements in warfarin therapyLow-dose aspirin: dosing in renal insufficiencyDrug-drug interaction: aspirin and ACE inhibitorWarfarin and paracetamol: drug-drug interactionACE inhibitor or sartan for diabetic patients with albuminuriaGlimepiride warning in renal insufficiencyLDL-cholesterol concentration in patients with type 2 diabetesHigh BNP or proBNP; untreated congestive heart failure (CHF)?Initial laboratory examinations in patients with congestive heart failure (CHF)Beta blockers in the prevention of gastrointestinal bleeding in patients with cirrhosisACE inhibitors or angiotensin receptor blockers for patients with diabetes and hypertension but no microalbuminuriaBesides the VTE prevention therapy reminders, other scripts were chosen for development and tailored to the hospital’s needs. The following alerts were identified by the hospital’s clinicians as of special interest:The validity of this RCT relies on the actual implementation of MediDSS by physicians in their clinical activities. Healthcare service studies on CDSSs, however, consistently suggest that the mere provision of such technology does not guarantee its uptake. In fact, even if a CDSS is readily available within a hospital, clinicians often fail to follow its recommendations, ignoring in some cases up to 96 % of its alerts . Given tWhen feasible, the trial will be tailored to address the specific needs emerging from the qualitative assessment. We will collect feedbacks about usability, possible errors, or inaccuracies of the information and recommendations provided. We will offer the best possible solutions to clinicians and hospital staff to overcome these problems. We will further organize and facilitate group discussions among participants to address negative perceptions or misleading beliefs about CDSSs. The qualitative study seeks to support the use of CDSS by participants, thus increasing the integrity of the intervention and associated compliance.Primary outcome: the rate at which the medical problems, which are detected by the MediDSS software and reported through the reminders, are resolved .Secondary outcomes: (i) resolution rates for the VTE prevention reminders, (ii) in-hospital all causes mortality (iii) VTE-related mortality, (iv) in-hospital morbidity for VTE-related causes, and (v) the length of hospital stay during the study period.We calculated the sample size on the basis of the primary outcome. A previous systematic review assessing the effects of computer reminders delivered to clinicians at the point-of-care on healthcare processes and outcomes found a median improvement of 4.2 % in process adherence across all reported process outcomes . AccordiMoreover, based on a prior study evaluating EBMeDS, which recorded an average of 0.30 reminders per individuals triggered at baseline , we deteAnonymous patient identification (ID) numbers in the EHR system will be the unit of randomization. An individual external to the study group will generate the anonymous IDs using a formula based on patients’ unique fiscal code numbers.We will randomly assign patients to either the control or experimental group with a 1:1 allocation. We will follow a computer-generated randomization schedule stratified by gender and age  using permuted blocks of random sizes . PatientPatients and study investigators  will be blinded to the allocation of participants. We will maintain the blinding up to the dataset disclosure. On the other hand, blinding of physicians is not feasible due to the nature of the intervention: the physician will know that a patient has been allocated to the intervention group if an automatic, patient-specific reminder is displayed on the screen.The data collection for this study will follow the standard data collection procedures of the AODV. We will collect demographic  and administrative  data from the EHR archive on a daily basis. Information on reminders, including all scripts that have been activated in a patient’s record, will also be collected daily, but during the night, so as not to disturb or slow down the use of the patient EHR.t test when normally distributed, and the non-parametric two-sample Wilcoxon rank-sum (Mann-Whitney) test when they are not normally distributed. We will compare categorical variables using the chi-squared test or the Fisher’s exact test, as appropriate. To model the resolution rates of the reminders, we will run a random effects logistic regression analysis, accounting for clustering by patient [For the primary outcome , the reminder will serve as the unit of analysis, and the patient the clustering factor. The patient will be the unit of analysis for the secondary outcomes . All analyses will follow the intention-to-treat principle: patients will be analyzed in the group to which they have been randomized. Descriptive statistics will be presented as means ± standard deviations (SD), medians and interquartile ranges (IQR), or percentages when appropriate. We will compare continuous variables using the Student’s  patient .For hypothesis testing, we will consider a probability level of less than 0.05 as statistically significant. All statistical tests will be two-sided. We will use the Stata software to perform all statistical analyses .(i)Sample size recalculation: Because the sample size calculation utilizes several assumptions, we will analyze the first batch of data collected and adjust the estimated sample size, if necessary, at the end of the sequential roll-out of the intervention. The 24-month recruitment period may also be adjusted, accordingly.(ii)Interim analysis: We will perform an interim analysis on the primary endpoint after 50 % of the patients have been randomized, after 50 % of the expected events have occurred, or after 12 months of the study’s initiation , whichever occurs first. An independent statistician that is blind to the patient allocation will perform the analysis. This analysis will inform whether the intervention has been proven for efficacy (beyond reasonable doubt). We will subsequently decide whether (or not) it is necessary to modify the study or prematurely terminate it, if necessary.(iii)End of trial: The end of trial will occur 30 days after the randomization of the last EHR. We will submit an end of trial notification and final report to the competent ethical committee, the AODV, and to the sponsor.Data monitoring will inform the CODES trial conduct, identifying the potential need for adjustments:We do not anticipate any harms (or other unintended effects) to study participants. Intervention and control groups will differ in the presence (intervention) or absence (control) of automatic reminders displayed on physicians’ monitors. Patients assigned to the control group will receive usual care without the reminders. Nevertheless, we will consult an external advisory board in the event that the discontinuation of the study becomes an option due to unforeseeable reasons.This study is conducted in accordance with the principles of the Declaration of Helsinki (October 2013) . As the Any changes to the research protocol that may impact the study conduct  will require a formal amendment of the protocol. We will communicate any such amendments to the trial registry  and notify the health authorities in accordance with the Italian regulations. We will further seek the approval of the Ethical Committee for any amendments to the protocol.The trial staff will ensure the maintenance of participants’ anonymity. The participants will be identified only by their initials and anonymous patient ID number. Depersonalized data will be extracted from the EHR. All documents will be stored securely and accessible only by the trial investigators and authorized personnel.Clinical data collected during the study will only be accessible to the staff at AODV, thus complying with the current medical practice of the hospitals. The trial investigators external to the hospitals  will not have access to any information at the patients’ level.The CODES trial will comply with the Italian Data Protection Act, which requires data to be anonymized as soon as it is practical to do so.The trial results will be posted on ClinicalTrials.gov as well as published in an open-access medical journal.We will further disseminate the study results to the health professionals of AODV who are involved in the study.The CODES trial has several strengths. First, the randomized controlled study design is recognized as the “gold standard” for testing intervention outcome hypotheses, allowing us to maximize the likelihood that the differences observed between groups are due to the intervention rather than potential confounding factors. Second, the pragmatic design of the study under conditions that mimics the actual use of CDSSs in practice increases the generalizability of the results as well as allows a more accurate estimation of the intervention’s true effectiveness. Third, the choice of an intention-to-treat analysis helps to ensure the pragmatic design of the study; in other words, although not all physicians may adhere to the reminders within the study, we anticipate that the lack of compliance with evidence-based recommendations occurs in everyday practice.We must note the methodological limitation that physicians will not be blinded to the treatment allocation. When a patient-specific reminder is automatically displayed on the monitors, the physician will know that the particular patient belongs to the intervention group. We are aware that the unit of allocation  and the lack of physician blinding can lead to possible group contamination as one physician can have both intervention and control group patients; in this case, a physician may apply the knowledge from a reminder generated for an intervention group patient to a control group patient. This possible learning effect (contamination of knowledge) can decrease the trial effect and lead to a more conservative effect estimate . Randomization at the physician level, however, does not eliminate the possibility of contamination as physicians can care for patients across different wards; this level of randomization would, moreover, increase the organizational complexity of the study.The use of CDSSs in healthcare systems is likely to increase in the near future due to (i) growing concerns about the quality of medical care; (ii) continuous calls for a meaningful use of health information technology; and (iii) increasing use of and familiarity with advanced technology among new generations of physicians.Through our pragmatic trial, we will contribute to the current research and understanding of the effectiveness of CDSSs in primary care and hospital settings. The results of our study may inform future research and healthcare policy questions related to the feasibility and value of CDSS use in healthcare systems.The implementation phase of the study was completed in November 2015, when the CDSS (MediDSS) was fully integrated with the hospital’s EHR (Tabula Clinica). Subject recruitment and data collection began in December 2015 in the Vimercate Hospital.CDSS, computerized decision support system; CODES, computerized decision support; EBM, evidence-based medicine; EBMeDS, Evidence-Based Medicine electronic Decision Support; EHR, electronic health record; GFR, glomerular filtration rate; IQR, interquartile range; MediDSS, Medilogy Decision Support System; RCT, randomized controlled trial; SD, standard deviation; VTE, venous thromboembolism


Background: In Germany medical students should gain proficiency and specific skills in the vaccination field. Especially important is the efficient communication of scientific results about vaccinations to the community, in order to give professional counseling with a complete overview about therapeutic options.Aim of the project: The aim of this project is to set up a vaccination-related curriculum in the Medical Faculty at the Ludwig-Maximilians-University in Munich. The structure of the curriculum is based on the National catalogue for competency-based learning objectives in the field of vaccination . Through this curriculum, the students will not only acquire the classical educational skills concerning vaccination in theory and practice, but they will also learn how to become independent in the decision-making process and counseling. Moreover, the students will become aware of consequences of action related to this specific topic.Methods: According to defined guidelines, an analysis was performed on courses, which are currently offered by the university. A separate analysis of the NKLM was carried out. Both analyses identified the active courses related to the topic of vaccination as well as the NKLM learning objectives. The match between the topics taught in current courses and the NKLM learning objectives identified gaps concerning the teaching of specific content. Courses were modified in order to implement the missing NKLM learning objectives.Results: These analyses identified 24 vaccination-related courses, which are currently taught at the University. Meanwhile, 35 learning objectives on vaccination were identified in the NKLM catalogue. Four of which were identified as not yet part of the teaching program. In summary, this interdisciplinary work enabled the development of a new vaccination-related curriculum, including 35 learning objectives, which are now implemented in regular teaching courses by the Medical Faculty.Conclusions: This project successfully describes a method to develop and implement a competency-based teaching program on the topic of vaccination. Importantly, the process presented here can serve as a guide to develop and implement similar teaching programs on other subjects and Universities. Vaccination belongs to the most important preventive measures against infectious diseases. High vaccination rates also protect individuals who decide not to vaccinate. This is important in order to decrease the infection rate in the whole population, and also to create an immunity, which protects individuals, who cannot or do not want to adhere to medical immunization, a sub-population considered to be in special need of protection against dangerous agents in the society .For this reason in 2013 the Coalition Agreement of the Federal Government of Germany stressed the urgency of increasing the vaccination rate . In partThe German Scientific Council suggests a competency-based rearrangement of the study program . CompeteThe Gesellschaft für Medizinische Ausbildung (GMA) und the Medizinische Fakultätenrat (MFT) developed the national competency-based curriculum in medicine called the Nationaler Kompetenzbasierter Lernzielkatalog Medizin (NKLM) . At the The approach to develop the new competency-based curriculum on vaccination is oriented toward the model of the Kernzyklus (modified accordingly to Kern) for the curriculum development in the Medical Faculty .The following steps are included:Needs and problem identification Target groupObjective goalsStrategy and MethodRealization/ImplementationDisease outbreaks, which can be prevented by vaccination, are often related to a lack of attention to vaccinations leading to a high rate of individuals not inoculated . The rolA competency-based curriculum for vaccination should prepare students to cope with constantly changing requirements in the handling of patients and in related counseling. The achievement of this goal is now addressed to students of the Medical Faculty of LMU (Munich). The following learning objectives were discussed within an expert-team and described accordingly to Guilbert : “At theThe vaccination curriculum was developed in 2 steps within 6 months. First of all, an analysis of the current teaching program was carried out. Next learning objectives were identified in the NKLM catalogue and subsequently matched to the topics of ongoing lectures. An interdisciplinary team of experts composed of professors, teaching personal, the academic dean, a health research scientist and a medical student took part in the whole project.The team of experts researched the current learning objectives in the 2013 summer term handbook of modules of the Medical Faculty at LMU. They estimated how often a student completing the 9 Semester course, came across vaccination topics during classes and seminars. “Vaccination topics” – accordingly to the module manual of inoculation practice  were defProduction of vaccineEffectiveness of vaccineRecommendation for the vaccine (Ständige Impfkommission STIKO)Execution of vaccine (including patient safety instructions)Ideological position Evaluation of the vaccine trialsLegal basis Subsequently, the team of experts extrapolated the learning objectives on vaccination from the NKLM catalogue. A qualified discussion decided upon inclusion or exclusion of discordant learning objectives. The result was a catalogue of NKLM learning objectives on vaccination. The catalogue included 35 learning objectives on vaccination. In addition a medical doctor specialized in general practice and specifically in the field of vaccination, developed a new curriculum about vaccination. The content of this experience-based curriculum was matched with the topics of the NKLM learning objectives on vaccination showing that the experience-based curriculum is only one part of the newly developed NKLM curriculum. Afterwards the NKLM learning objectives on vaccination were matched to the topics of the current teaching program to address gaps in the current teaching program.Comparing the NKLM catalogue to the current LMU curriculum led to the identification of learning objectives which were not yet part of the present teaching program. To overcome this issue, the missing topics were implemented in the teaching by modifying LMU courses.The analysis of the teaching modules at the LMU identified 24 lectures about vaccination topics  was analyzed according to the following topics of the NKLM: roles of competency and medical expertise (see Figure 3 31 out of 35 learning objectives from the NKLM catalogue about vaccination were already part of the current teaching program, while 4 of them were found to still be missing. The current teaching courses were modified to include the missing learning objectives. The missing objectives were integrated in different forms within the teaching program: 3 were included in seminars, and 1 was included in a lecture (see Table 2 In conclusion, the newly developed NKLM curriculum about vaccination in the Medical Faculty at LMU now contains all 35 learning objectives all integrated into the new teaching program. A method to develop a competency-oriented curriculum based on the NKLM was carried out in a number of steps. After performing an analysis of the present teaching program, the learning objectives concerning vaccination were identified. Subsequently, the current learning objectives from the LMU teaching program were matched with the NKLM learning objectives. The next step identified missing learning objectives which were afterwards integrated into the teaching program. Since the educational activities are modified and new learning objectives are now fixed, a reduction of the course content could take place. However, it was important to ensure the teaching of all topics, including several that were outside of the new reassessment of the teaching program. For example, it was possible to substitute the topic “Cough” with the topic “Vaccination”, given that the new topic included basic competences like counseling and a background about the decision process. In this case, although the topic “Cough” was replaced by the topic “Vaccination”, the learning objectives on counseling skills, were still delivered within the courses. This analysis of the teaching program revealed to conclusions about lectures concerning the number, type, level of competence, and timing of the lectures. The analysis also elucidated redundancy. These results have been shown in a Curricular Mapping. The subject vaccination is now part of the longitudinal program at the LMU, and it covers all the teaching levels. Competences such as scientific skills, which were not yet part of the program, were integrated into the teaching through changes in the curriculum. These methods used for the topic vaccination can be applied as well for other comprehensive topics in medical education. The identification of learning objectives in the NKLM for a specific topic served as motivation for the team to carefully screen the NKLM catalogue. The team became aware of the rigidity of the NKLM catalogue. Some believed that the NKLM learning objectives do not promote freedom of inquiry in research and teaching. For this reason, a discussion concerning the relevance of the NKLM learning objectives catalogue arose. It was suggested that the NKLM could serve better as a fixed framework for the preparation of a catalogue with learning objectives. The lecturer can feel free to adopt NKLM learning objectives in detail or individually formulate their own learning objectives including them within the NKLM objectives. Therefore this method can be adjusted to individual parameters in local curricula still insuring fixed standards.This paper describes a new approach for the development of competency-based curriculum on the topic vaccination. Our work showed the teaching process can be improved through the determination of competency-oriented learning objectives, the clear assignment of responsibility, and the integration of missing topics. Moreover, this approach can contribute to transparency in the teaching program. After the development of the new curriculum about vaccinations, the new catalogue with the updated learning objectives will be evaluated. For example, professors will be asked about the utility of the newly produced catalogue containing the learning objectives, asking them whether it was useful for setting up their list of the topics to teach during the lectures. Moreover, the students will be asked about the NKLM learning objectives. They will be asked whether the new teaching program is helpful toward their preparation for the final exam in general practice. The project revealed a dynamic method, for new curriculum development. After positive evaluation results, this method can be applied not only for small topics such as “vaccination,” but also for extended subjects in other universities, in order to develop and implement competency-based learning objectives catalogues. The authors acknowledge the constructive contribution during the preparation of the competency-based curriculum for teaching of the topic vaccination provided by Prof. Dr. med. Bogner, Prof. Dr. med. Eberle, Prof. Dr. med. Hübner, Prof. Dr. med. von Kries, PD Dr. rer. nat. Obst and Dr. med. Schrörs.The authors declare that they have no competing interests.The German title was supplemented with the word "Impfen".


Given the constantly raising world-wide energy demand and the accompanying increase in greenhouse gas emissions that pushes the progression of climate change, the possibly most important task in future is to find a carbon-low energy supply that finds the right balance between sustainability and energy security. For renewable energy generation, however, especially the second aspect turns out to be difficult as the supply of renewable sources underlies strong volatility. Further on, investment costs for new technologies are so high that competitiveness with conventional energy forms is hard to achieve. To address this issue, we analyze in this paper a non-autonomous optimal control model considering the optimal composition of a portfolio that consists of fossil and renewable energy and which is used to cover the energy demand of a small country. While fossil energy is assumed to be constantly available, the supply of the renewable resource fluctuates seasonally. We further on include learning effects for the renewable energy technology, which will underline the importance of considering the whole life span of such a technology for long-term energy planning decisions. Facing the impacts of climate change, the rapid economic growth coming along with a higher energy demand as well as the fact that one of the main contributors to the constantly increasing green house gas emissions is given by the energy sector, the possibly biggest problem of this century will be to find a carbon-low, sustainable, and simultaneously secure energy supply. Therefore, the incentives for developing and improving renewable energy technologies have changed during the past decades. Originally, the driving force has been given by the rapidly narrowing horizon of depletion of fossil fuels. However, due to the development of new extraction techniques and the discovery of new sources nowadays, the threats of global warming play a major role. Mitigation policies supporting investments into renewable energy technologies should reduce the emissions and slow down the global warming process. The available alternatives of energy generation in the future, however, strongly depend on structural and technological changes together with the accompanying investment decisions right now, because the development and the diffusion of a new technology is a time-intensive dynamic process  and focus on solar energy as renewable resource. To give an example for the seasonal supply of solar energy, Fig. mentclass2pt{minimata ZAMG  for estit which therefore makes the problem non-autonomous.As depreciation is considered in the model, investments ESince the representative energy sector decision maker is assumed to have exact information about the required energy demand entclass1pt{minimaöderholm , who prey et al. . The newcurrent-value HamiltonianLagrangian  which reads asLet oblem in ; then, aoblem in , there estraints  and 3d)\documententclass1pt{minimax(t) is a solution of the canonical system, also k is a solution. Due to this periodicity in the dynamics, a candidate for the optimal long-run solution of the problem in   5) is nooblem in , which ioblem in , which aoblem in  and (5) ribed in  for eachJ(t) is the Jacobian matrix evaluated at the periodic solution In order to analyze the dynamic behavior of an obtained periodic solution l system  and 5)  \documenF is spanning the orthogonal complement to the stable eigenspace \documententclass1pt{minimaentclass1pt{minimaThe time-control paths and the time-state paths of the two saddle-type solutions are shown in more detail in Fig. Such seasonal maintenance planning can be observed in various fields of energy generation. For hydro storage power stations, for example, the seasonality is given by the natural inflows, which usually are higher in early spring due to snow melting and lower over summer during droughts. Also here, maintenance activities are mainly done during the less productive period in summer, in order to keep opportunity costs of a reduced machine availability low. Also thermic power plants usually have their revisions during periods of reduced operating hours due to a lower energy demand (e.g. summer).Summing up the obtained solutions, we have two periodic solutions being of saddle-type whose areas of attraction probably are separated by an indifference threshold point induced by the unstable focus in between. Indifference threshold points are points in the state space at which the paths leading into different optimal long-run solutions have the same objective value. Therefore, at these points one is indifferent between the two solutions. For more details on indifference threshold points  the continuation process aborts as the path reaches some feasible boundary, (2) the path is bending back, or (3) the other periodic solution is reached. The results of these continuations can be seen in Fig. The occurrence of an indifference threshold point is an important result of this analysis as the optimal long-run periodic solution depends on the initial capital stock with which optimization is started.Figure This result points out the difficulty of introducing a new energy technology into the market. While conventional energy types already are competitive and have low prices due to the high experience accumulated over years, the investment costs for new technologies are very high. As no experience exists at the beginning, these high investment cost would have to be paid over some period of time during which the new technology definitely is not profitable, until finally at least some reduction due to accumulated experience is archived which would be the very first step on the long way towards the break even point. This aspect underlines the importance of subsidies and other kind of financial support that is necessary during the starting-up period to help new technologies over this barrier. Such temporary incentives, also known as directed technical change, can be fundamental for the inclusion of clean technologies. See for this Acemoglu et al. , where iAs accumulated experience improves the technical processes and hence reduces the necessary financial effort, the technology gets more profitable. However, it can take a long time until full competitiveness with the conventional technology is achieved, which happens at the so-called break-even point.To analyze the extend of the learning-by-doing effect on the investment costs in our model, we compare the costs of renewable energy generation with the fossil energy price The analysis of the previous section has shown that the learning-by-doing effect can imply history dependence of the optimal long-run periodic solution. The driving force for this dependence is given by the cost-effectiveness of renewable energy generation with respect to conventional energy technologies. However, there are several factors beyond historical capital accumulation activities that influence this cost-effectiveness. First of all, of course, the fossil energy price t and for the current parameter set and the fossil solution is given as In the first step, we focus on the influence of the fossil energy price on the optimal portfolio composition. We use numerical continuation with respect to the fossil energy price Figure As already mentioned, not only the fossil energy price plays an important role how the optimal portfolio composition looks like, but also the reducing impact of the learning-by-doing effect on the investment costs of renewable energy, which is determined by the learning coefficient We fix the fossil energy price at So far we have investigated the impact of price and learning-by-doing effects on the optimal portfolio composition. However, we completely have fixed site-specific aspects concerning the supply of global radiation for the previous analysis. Therefore, an interesting aspect on which we focus on in the following is as to how the solutions change when geographical conditions vary.For the estimation of the parameter values mentclasspt{minimaIn order to investigate the changes in the optimal portfolio composition when site-specific parameters change, we conduct the same sensitivity analysis with respect to the fossil energy price Figure First, we focus on Scenario 1 with a less intensive supply of global radiation. It shows that the qualitative behavior is the same. For a low fossil energy price only the fossil solution exists, while at a specific point the two mixed solutions, with one being unstable and the other one being of saddle-type, occur and the areas of attraction are separated by an indifference threshold curve. However, a look on the price axis makes clear that remarkable changes concerning the position have happened. While the first bifurcation point at which these two additional mixed periodic solutions exists has been at Second, we investigate Scenario 2 with a higher intensity of global radiation. Also for this case, the qualitative outcome does not change, but again the price boundaries are of special interest. While the interval, in which all three long-run periodic solutions exist and the area of attraction is separated by an indifference threshold point, started at Varying the intensity of the site-specific global radiation has shown some interesting aspects. While in all three cases, the original parameter set as well as the two scenarios, the intensity of the learning-by-doing effect is exactly the same, the outcomes and their possible consequences for political decisions are completely different. In reality, of course, the price boundaries between which the indifference threshold curve separates the areas of attraction are hard to observe and the only indicator for subsidy decisions might be given by the current fossil energy price. Assume, that in all three cases a price level of We have investigated in this paper how a small country’s optimal composition of a portfolio consisting of fossil and renewable (solar) energy looks like, when the effect of learning by doing reduces the investment costs due to accumulated experience. Modeling the problem as a non-autonomous optimal control model, we have included a one-factor log-linear learning curve into the objective function so that the accumulated renewable energy capital, which is supposed to reflect the collected experience, has a diminishing impact on the investment costs. Further on, we postulated seasonally varying renewable energy supply and a well-known energy demand that has to be covered.The obtained results have shown that the fluctuating supply of the renewable resource is one of the major challenges for renewable energy generation. Even if the break even point for the renewable energy technology could be reached where it gets competitive, the shortfalls in winter still have to be covered with fossil energy. This, however, implies another problem which can be seen at the current market situation. As no resource costs occur for renewable energy generation, the variable costs are almost zero, well in contrast to fossil energy. Therefore, a too high renewable energy generation could jeopardize the competitiveness of fossil energy and, hence, its capability to cover these shortfalls. However, as long as the renewable energy generation is not autarkic, for example due to the help of supportive storage systems, fossil energy is urgently needed as backup.Sensitivity analysis with respect to the fossil energy price The occurrence of an indifference threshold point yields important aspects for the economic interpretation of the obtained results. We have seen that whether investments into renewable energy generation capital are worthwhile or not depends on the initial capital stock. Due to this history dependence, investments into renewable energy generation from the very beginning never would be optimal in our approach as the initial investment costs are too high. The level of the capital stock, at which such investments get profitable, shifts even further up if global radiation is lower, as for the northern countries, or if the learning-by-doing effect is weaker, meaning that the learning coefficient is assumed to be lower. One important conclusion of these results is that financial support in form of subsidies during the starting up period of a new technology could play a major role for the successful introduction of this technology into the market. The profitability, however, strongly depends on the site-specific conditions.The most important aspect for an increasing renewable energy generation in our model has been given by accumulated experience. This learning-by-doing effect, however, has been restricted to the considered country itself. In reality, of course, learning by doing is not only a national but also an international issue. Knowledge spillovers between different countries would even enforce the learning effect and, hence, the adaption of renewable energy technology would happen much faster. Synergies between different countries, therefore, could shift the indifference threshold point to the left and, consequently, a lower subsidy effort would be necessary to support the inclusion of renewable energy generation into the portfolio.While international cooperation can be supportive for accumulating experience with renewable energy generation, the results from the sensitivity analysis with respect to the global radiation intensity have shown that the effectiveness of a subsidy system strongly depends on national conditions. This means that a cross-border subsidies policy might overlook such tiny but important differences between countries, which could make the subsidies ineffective, as we have seen in Sect. Experience in this approach has been the driving force for the reduction of investment costs. But this is not the only source for technological learning. Of course also research and development efforts could foster the competitiveness of a new technology, which implies accumulation of knowledge and, hence, an additional reduction in investment costs. The extension of the model with this aspect will be of special interest in one of our future works.


Information from complementary and redundant sensors are often combined within sensor fusion algorithms to obtain a single accurate observation of the system at hand. However, measurements from each sensor are characterized by uncertainties. When multiple data are fused, it is often unclear how all these uncertainties interact and influence the overall performance of the sensor fusion algorithm. To address this issue, a benchmarking procedure is presented, where simulated and real data are combined in different scenarios in order to quantify how each sensor’s uncertainties influence the accuracy of the final result. The proposed procedure was applied to the estimation of the pelvis orientation using a waist-worn magnetic-inertial measurement unit. Ground-truth data were obtained from a stereophotogrammetric system and used to obtain simulated data. Two Kalman-based sensor fusion algorithms were submitted to the proposed benchmarking procedure. For the considered application, gyroscope uncertainties proved to be the main error source in orientation estimation accuracy for both tested algorithms. Moreover, although different performances were obtained using simulated data, these differences became negligible when real data were considered. The outcome of this evaluation may be useful both to improve the design of new sensor fusion methods and to drive the algorithm tuning process. Sensor fusion is a signal processing technique that combines data measured by multiple sources in order to create a single measurement system with an augmented performance over each standalone sensor ,2. The ri.e., the sum of the external and gravitational accelerations), and the Earth’s magnetic field, respectively. The 3D body orientation can be estimated through the numerical integration of the rotational kinematic equation of a rigid body, by using angular velocity measurements and known initial conditions. The accelerometer and the magnetic sensors are supposed to track two external reference vectors: the Earth gravity acceleration  and the Earth magnetic field (heading reference vector). Estimating the body orientation by comparing the reference vectors measured in the body frame with their known counterparts expressed in an inertial reference frame, is known as field vector matching [SFAs are widely employed in several applications including autonomous navigation, robotics, environmental monitoring, and healthcare ,3,4,5. Imatching . Usuallymatching ,10,11,12matching ,14. On ti.e., the angular velocity, the specific force, and the Earth magnetic field vector. For this reason, MIMU data may be considered uncorrelated to each other, i.e., no crosstalk among the three domains is expected. The only exception is the gyroscope sensitivity to the gravity and external accelerations [i.e., each sample of measured angular velocity, specific force, and magnetic field exhibits a degree of uncertainty [In this respect MIMU observations are disparate , in the erations  which, herations . Within erations , i.e., eertainty  which haertainty .i.e., the choice of different tuning settings or of the adaptive mechanisms to be built in the SFA) or to compare different combinations of sensor hardware components. Therefore, the development of benchmarking methods aimed at quantifying the effect of each sensor issue on the SFA performance is of the utmost importance. Nevertheless, no clear methodologies, guidelines, or tools for SFA performance assessment are available.Unfortunately, when sensor observations are fused in an SFA, it is very difficult to assess to which extent each sensor issue influences the final error. This information would be crucial to guide the SFA design process  was then created. Each scenario is a different combination of measured and/or simulated MIMU data. The SFA under analysis was then run using the data of each scenario as input, and the MOP was calculated by comparing the corresponding output with the reference one.Specifically, for the application investigated in the present study, ground-truth and real sensor data were acquired during a motion capture session. The ground-truth data were processed within the Ground-truth Data Processing block to obtain the reference output, which was used to simulate ideal sensor data (Data Simulation block). In addition it provided a reference for the calculation of the Measure Of Performance (MOP), The considered case study is the estimation of the pelvis orientation, by using data measured by a waist-worn MIMU, during a Timed Up and Go test (TUG) , which i2, ±1500°/s and ±600 μT of full-range scale, respectively), was secured to the participants’ lower back , embedding a tri-axial gyroscope, accelerometer, and magnetic sensor . At this point in time, both the experimental and the ideal data required to devise the different scenarios for the SFA evaluation were available.In order to obtain simulated  MIMU data, the ground-truth body orientation ribed in . In partformulae . The samTo isolate the influence of the errors characterizing each MIMU sensor and to quantify the efficacy of the adaptive mechanisms built in to test SFAs, the following scenarios were defined : (a) twoTwo Kalman-based orientation estimators were benchmarked in this work by using the proposed approach . The pseD method  for singAlgorithm 2 is the Extended Kalman Filter (EKF) presented in . In the The combination of ideal and/or measured angular velocity, acceleration, and magnetic field vector data, associated with each above-mentioned scenario, were fed into both Algorithms 1 and 2. For each SFA and time sample, six orientation estimates were obtained (one for each scenario) and each of them was compared to the ground-truth body orientation, as explained in The accuracy in estimating the MIMU orientation was expressed in terms of orientation error computed as the quaternion that rotates the estimated MIMU orientation posed in :(1)Δq^kThen, in accordance with , Δq^kbn irection ,23. The The MOP was computed for each scenario, SFA, and trial performed by each subject.In order to assess the performance of both Algorithms 1 and 2, the following specific questions were considered: (i) To which extent the SFA performance is affected by the errors characterizing each MIMU sensor? (ii) Can the SFA mitigate the effect of these sensor-specific errors, at least when all other sensors’ data are considered to be as ideal? (iii) How do different SFAs behave when fed with either simulated or real sensor signals?post-hoc pairwise tests were used to compare the GYR, ACC, and MAG scenarios with both the SIM and MEAS scenarios in order to answer (i) and (ii), respectively. In addition, the same test was adopted to compare the MOD and SIM scenario in order to assess the effect of the external acceleration on the SFAs output.For what concerns questions (i) and (ii) , a one way repeated-measures ANalysis Of VAriance (ANOVA) was performed, using the scenario as a factor, on both the attitude and heading accuracy obtained for each method, separately. The MOP values were transformed according to the Tukey Ladder of Powers in order to achieve normality, in case of a lack of normality revealed by the Shapiro-Wilk test. The Greenhouse-Geisser correction was used to take into account possible violations of the sphericity assumption. Given possible significant differences revealed by the ANOVA test for the scenario effect, the Dunn-Sidak’s In order to answer question (iii) , the presence of significant differences between the orientation accuracy obtained for Algorithms 1 and 2 was verified using a Wilcoxon test for both the SIM and MEAS scenarios. The alpha level of significance was set to 0.05 for all statistical tests.The heading and attitude ground-truth curves and the errors associated to each simulated scenario are reported in For what concerns the intra-algorithm comparisons, the results of the one-way repeated measures ANOVA are reported in post hoc tests was done according to the questions presented in The selection of the scenarios considered for the The results of the Wilcoxon test are reported in In the present study, a novel benchmarking method for SFAs performance assessment was presented and applied to a human movement analysis case study. In particular, the 3D pelvis orientation was estimated during a TUG test. A pool of hybrid scenarios, including both simulated and real MIMU data, was created and the combination of data associated to each scenario was fed to two different Kalman-based SFAs. The accuracy with which the pelvis orientation was estimated was then assessed by comparing the output of each algorithm with the reference output.In For both SFAs, the orientation errors were, on average, 3° and 4° for the attitude and heading, respectively . These epost-hoc analysis between the SIM and GYR scenarios revealed that using the simulated gyroscope data instead of the measured ones produced a significant effect for both attitude and heading accuracy, regardless of the considered SFA (vs. MEAS). This was always true except for the heading estimation obtained using Algorithm 1  do not convey heading information, errors in the accelerometer data cause errors in the heading estimation. This is also supported by the results of the comparison between the MOD and SIM scenarios: for both SFAs and both heading and attitude, a significant difference was observed between the two scenarios, which only differ for the presence of external accelerations (accelerometer inconsistency ). These When considering the heading estimation using both Algorithms 1 and 2, the errors associated to the MAG scenario were significantly different from those obtained for both the SIM and MEAS scenarios. On the other hand, for Algorithm 1, when the attitude is considered, no significant difference was observed between the MAG and SIM scenarios. This result may be explained as follows: within Algorithm 1 the actual orientation estimation is performed by the TRIAD block see , which uWith regard to the inter-algorithm comparison , when coAs a summary, the proposed benchmarking method has the benefit to allow for an improved understanding of the extent to which each sensor issue influences the final orientation estimate. This possibility is of paramount importance in the context of SFAs design to correctly consider the role of each sensor. As an example, by means of the proposed methodology the following considerations for the MIMU-based human motion tracking can be drawn: (1) the gyroscope errors appear to be the main error source for both the SFAs considered; (2) the processing of accelerometer data proposed in Algorithm 1 is promising because it reduces the detrimental effect of the external acceleration; (3) using the magnetometer data for the heading estimation only leads to more accurate attitude estimates. These considerations can then be used to improve the existing designs/tuning settings in accordance to the needs of the specific application.In conclusion, the methodology presented in this paper allows to gain insight into the working principles of a generic sensor fusion algorithm. The proposed data hybridization process consists in combining real and ideal sensor data with the aim of addressing the main strengths and weaknesses of an SFA. Moreover, the results obtained with this methodology when applied to multiple SFAs allow highlighting their specific behavior with respect to different input data issues. The proposed benchmarking method was applied to a typical sensor fusion context in human movement analysis, namely 3D orientation estimation through MIMU data. The potential of the proposed methodology was thus exploited to reveal the main issues involved in this specific application context.