Serious Infections in People with Systemic sclerosis: A National U.S. Study

Mapping Intimacies ◽

10.21203/rs.2.21866/v2 ◽

2020 ◽

Author(s):

Jasvinder Singh ◽

John D. Cleveland

Keyword(s):

Systemic Sclerosis ◽

Hospital Mortality ◽

Hospital Stay ◽

Healthcare Utilization ◽

Time Trends ◽

Length Of Hospital Stay ◽

Hospital Charges ◽

Home Setting ◽

Serious Infection ◽

Serious Infections

Abstract Objective: To study incidence, time-trends and outcomes of serious infections in systemic sclerosis (SSc). Methods: We used the 1998-2016 U.S. National Inpatient Sample data. We examined the epidemiology, time-trends and outcomes of five serious infections (opportunistic infections (OI), skin and soft tissue infections (SSTI), urinary tract infection (UTI), pneumonia, and sepsis/bacteremia) in hospitalized people with SSc. We performed multivariable-adjusted logistic regression analyses to analyze independent association of factors with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital mortality. Results: There were 49,904,955 hospitalizations with serious infections in people without SSc and 61,615 in those with SSc. During 1998-2016, the most common serious infections in SSc were pneumonia (45%), sepsis (32%), SSTI (19%), UTI (3%) and OI (3%). In 2013-14, sepsis surpassed pneumonia as the most common serious infection; by 2015-16, sepsis was 1.8-times more common than pneumonia. Over the study period, hospital charges increased, while length of hospital stay and in-hospital mortality decreased, overall and for each serious infection. Multivariable-adjusted analyses showed that sepsis, age ≥80 years and Deyo-Charlson score ≥2 were associated with significantly higher odds of healthcare utilization and in-hospital mortality; and Medicare or Medicaid insurance payer, Northeast location, urban teaching or non-teaching hospital, and medium or large hospital bed size with significantly higher odds of healthcare utilization. Conclusions: Outcomes in people with SSc hospitalized with serious infections have improved over time, except higher hospital charges. Identification of factors associated with higher healthcare utilization and in-hospital mortality allows for developing interventions to improve outcomes.

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Serious Infections in People with Scleroderma: A National U.S. Study

10.21203/rs.2.21866/v1 ◽

2020 ◽

Author(s):

Jasvinder Singh ◽

John D. Cleveland

Keyword(s):

Hospital Mortality ◽

Hospital Stay ◽

Healthcare Utilization ◽

Time Trends ◽

Opportunistic Infections ◽

Length Of Hospital Stay ◽

Hospital Charges ◽

Home Setting ◽

Serious Infection ◽

Serious Infections

Abstract Objective: To study incidence, time-trends and outcomes of serious infections in scleroderma. Methods: We used the 1998-2016 U.S. National Inpatient Sample data. We examined the epidemiology, time-trends and outcomes of five serious infections (opportunistic infections (OI), skin and soft tissue infections (SSTI), urinary tract infection (UTI), pneumonia, and sepsis/bacteremia) in hospitalized people with scleroderma. We performed multivariable-adjusted logistic regression analyses to analyze independent association of factors with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital mortality. Results: There were 49,904,955 hospitalizations with serious infections in people without scleroderma and 61,615 in those with scleroderma. During 1998-2016, the most common serious infections in scleroderma were pneumonia (45%), sepsis (32%), SSTI (19%), UTI (3%) and OI (3%). In 2013-14, sepsis surpassed pneumonia as the most common serious infection; by 2015-16, sepsis was 1.8-times more common than pneumonia. Over the study period, hospital charges increased, while length of hospital stay and in-hospital mortality decreased, overall and for each serious infection. Multivariable-adjusted analyses showed that sepsis, age ≥80 years and Deyo-Charlson score ≥2 were associated with significantly higher odds of healthcare utilization and in-hospital mortality; and Medicare or Medicaid insurance payer, Northeast location, urban teaching or non-teaching hospital, and medium or large hospital bed size with significantly higher odds of healthcare utilization. Conclusions: Outcomes in people with scleroderma hospitalized with serious infections have improved over time, except higher hospital charges. Identification of factors associated with higher healthcare utilization and in-hospital mortality allows for developing interventions to improve outcomes.

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Hospitalized Infections in People with Osteoarthritis: A National U.S. Study

The Journal of Rheumatology ◽

10.3899/jrheum.191383 ◽

2020 ◽

pp. jrheum.191383

Author(s):

Jasvinder A. Singh ◽

John D. Cleveland

Keyword(s):

Healthcare Utilization ◽

Opportunistic Infections ◽

Hospital Charges ◽

Inhospital Mortality ◽

Infection Rates ◽

Urban Hospital ◽

Large Hospital ◽

Home Setting ◽

Serious Infection ◽

Serious Infections

Objective To study the incidence, time-trends and outcomes of serious infections in people with osteoarthritis. Methods We used the 1998-2016 U.S. National Inpatient Sample data. We examined the epidemiology of five hospitalized, i.e., serious infections (opportunistic infections (OI), skin and soft tissue infections (SSTI), urinary tract infection (UTI), pneumonia, and sepsis/bacteremia) in people with osteoarthritis, using recommended weights. We performed multivariable-adjusted logistic regression analyses to analyze factors associated with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital mortality. Results Of all serious infection hospitalizations, 46,708,154 were without osteoarthritis, and 3,258,416 had osteoarthritis. Respectively, people with OA were 16 years older, more likely to be female (52% vs. 65%), White (59% vs. 70%), have Deyo-Charlson index score ≥2 (41% vs 51%), Medicare (54% vs. 80%), and less likely to receive care at an urban teaching hospital (45% vs. 39%). Serious infection rates /100,000 NIS hospitalizations increased from 1998-2000 to 2015-2016: OI from 4.5 to 7.2; SSTI, 48.3 to 145.8; UTI, 8.4 to 104.6; pneumonia, 164.0 to 224.3; sepsis, 39.4 to 436.3. In multivariable-adjusted analyses, older age, higher Deyo-Charlson score, sepsis, Northeast region, urban hospital and medium or large hospital bed size were significantly associated with higher healthcare utilization outcomes and inhospital mortality; and Medicaid insurance, non-White race, and female sex with higher healthcare utilization. Conclusion Serious infection rates have increased in people with osteoarthritis. Association of demographic, clinic and hospital variables with serious infection outcomes identifies potential targets for future interventions.

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Sjogren’s Syndrome is associated with higher healthcare utilization after primary hip, but not primary knee arthroplasty: A U.S. cohort study

10.21203/rs.2.24230/v1 ◽

2020 ◽

Author(s):

Jasvinder A Singh ◽

John D. Cleveland

Keyword(s):

Hospital Stay ◽

Healthcare Utilization ◽

Length Of Hospital Stay ◽

Sjogren’S Syndrome ◽

Sjogren's Syndrome ◽

Hospital Charges ◽

Implant Infection ◽

Home Setting ◽

Primary Thas ◽

Primary Tkas

Abstract Objective: To assess whether Sjogren’s Syndrome (SS) is associated with outcomes after total knee or hip arthroplasty (TKA/THA).Methods: We used the 1998-2014 U.S. National Inpatient Sample data. We performed multivariable-adjusted logistic regression analyses to assess the association of SS with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital complications (implant infection, revision, transfusion, mortality), controlling for important covariates and confounders. In sensitivity analyses, we additionally adjusted the main models for hospital location/teaching status, bed size, and region.Results: We examined 4,116,485 primary THAs and 8,127,282 primary TKAs performed from 1998-2014; 12,772 (0.2%) primary TKAs and 6,222 (0.2%) primary THAs were done in people with SS. In multivariable-adjusted models, SS was associated with a statistically significant higher odds ratio (OR; 95% confidence interval (CI)) of discharge to a rehabilitation/inpatient facility post-THA, 1.13 (1.00, 1.28), but not post-TKA, 0.93 (0.86, 1.02). We noted no differences in the length of hospital stay or hospital charges. SS was associated with significantly higher adjusted odds of in-hospital transfusion post-THA, 1.37 (1.22, 1.55) and post-TKA, 1.21 (1.10, 1.34). No significant differences by SS diagnosis were seen in hospital stay, hospital charges implant infection, implant revision or mortality rates.Conclusions: People with SS had higher transfusion rate post-TKA/THA, and higher rate of discharge to non-home setting post-THA. The lack of association of SS with post-arthroplasty complications should reassure patients, surgeons and policy-makers about the utility of TKA/THA in people with SS undergoing these procedures.

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Sjogren’s Syndrome is associated with higher healthcare utilization after primary hip, but not primary knee arthroplasty: A U.S. cohort study

10.21203/rs.2.24230/v2 ◽

2020 ◽

Author(s):

Jasvinder A Singh ◽

John D. Cleveland

Keyword(s):

Hospital Stay ◽

Healthcare Utilization ◽

Length Of Hospital Stay ◽

Sjogren’S Syndrome ◽

Sjogren's Syndrome ◽

Hospital Charges ◽

Implant Infection ◽

Home Setting ◽

Primary Thas ◽

Primary Tkas

Abstract Objective: To assess whether Sjogren’s Syndrome (SS) is associated with outcomes after total knee or hip arthroplasty (TKA/THA). Methods: We used the 1998-2014 U.S. National Inpatient Sample data. We performed multivariable-adjusted logistic regression analyses to assess the association of SS with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital complications (implant infection, revision, transfusion, mortality), controlling for important covariates and confounders. In sensitivity analyses, we additionally adjusted the main models for hospital location/teaching status, bed size, and region . Results: We examined 4,116,485 primary THAs and 8,127,282 primary TKAs performed from 1998-2014; 12,772 (0.2%) primary TKAs and 6,222 (0.2%) primary THAs were done in people with SS. In multivariable-adjusted models, SS was associated with a statistically significant higher odds ratio (OR; 95% confidence interval (CI)) of discharge to a rehabilitation/inpatient facility post-THA, 1.13 (1.00, 1.28), but not post-TKA, 0.93 (0.86, 1.02). We noted no differences in the length of hospital stay or hospital charges. SS was associated with significantly higher adjusted odds of in-hospital transfusion post-THA, 1.37 (1.22, 1.55) and post-TKA, 1.21 (1.10, 1.34). No significant differences by SS diagnosis were seen in hospital stay, hospital charges implant infection, implant revision or mortality rates. Conclusions: People with SS had higher transfusion rate post-TKA/THA, and higher rate of discharge to non-home setting post-THA. The lack of association of SS with post-arthroplasty complications should reassure patients, surgeons and policy-makers about the utility of TKA/THA in people with SS undergoing these procedures.

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In-Hospital Outcomes in Patients With Hyperosmolar Hyperglycemic State With and Without Hypertriglyceridemia: Analysis of National Inpatient Sample

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.869 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A426-A426

Author(s):

Genaro Velazquez ◽

Hafeez Shaka ◽

Mukunthan Murthi ◽

Iriagbonse Asemota ◽

Sujitha Velagapudi ◽

...

Keyword(s):

Septic Shock ◽

Hospital Mortality ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Hospital Charges ◽

Secondary Diagnosis ◽

Total Hospital ◽

Mortality And Morbidity ◽

Lower Odds ◽

Hyperosmolar Hyperglycemic State

Abstract Background: In patients hospitalized with Hyperosmolar hyperglycemic state (HHS) the presence of comorbid conditions including hypertension, heart disease, stroke, and dementia have been variably reported to be associated with higher mortality. HTG is increasingly prevalent in patients with DM, especially those with poor glycemic control who are more likely to suffer from HHS. Elevated triglyceride levels have independently been associated with higher mortality in certain conditions like coronary artery disease and acute pancreatitis. However, data on the effect of Hypertriglyceridemia (HTG) on mortality and morbidity in hospitalized patients with HHS is sparse. Objective: We wanted to compare the outcomes for HHS hospitalizations for patients with and without HTG. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. About 42 740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of HTG as secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total Hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders. Results: Out of the 42 740 hospitalizations with HHS, about 17 040 had HTG. The in-hospital mortality for patients with HHS was 305 overall, out of which 70 patients had HTG as secondary diagnosis. Compared with patients without HTG, patients with HTG had lower odds of in- hospital mortality (0.30, 95% CI 0.157–0.56, p<0.005) when adjusted for patient and hospital characteristics. Patients with HHS and HTG had decreased length of hospital stay, less total Hospital charges, lower odds of Sepsis and Septic Shock, but similar odds of AKI and ARF in comparison to patients without HTG. Conclusion: Our study shows that HTG is associated with lower odds of in-hospital mortality in patients with HHS, even though the odds of AKI and ARF was same in both groups. A similar inverse relationship has already been reported between TG levels and mortality in stroke patients. Though the mechanism of this effect is unclear, one possible explanation could be that patients with HTG are more likely to be treated with statins and fibrates which have known anti-inflammatory effects. Further studies are required to evaluate this possible positive prognostic effect of TG.

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Path Analysis of the Impact of Obesity on Postoperative Outcomes in Colorectal Cancer Patients: A Population-Based Study

Journal of Clinical Medicine ◽

10.3390/jcm10132904 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2904

Author(s):

Kuan-Chih Chung ◽

Ko-Chao Lee ◽

Hong-Hwa Chen ◽

Kung-Chuan Cheng ◽

Kuen-Lin Wu ◽

...

Keyword(s):

Colorectal Cancer ◽

Hospital Mortality ◽

Hospital Stay ◽

Path Analysis ◽

Postoperative Infection ◽

Digestive System ◽

Length Of Hospital Stay ◽

Hospital Charges ◽

Perioperative Outcomes ◽

Total Hospital

Background: Obesity is adversely affecting perioperative outcomes; however, long-term outcomes do not appear to be affected by excess body weight (the obesity paradox). The purpose of this study is to examine the association between obesity and surgical outcomes in patients with colorectal cancer (CRC) using data from the United States National Inpatient Sample (NIS). Methods: Patients ≥20 years old diagnosed with CRC who received surgery were identified in the 2004–2014 NIS database. Patients who were obese (ICD-9-CM code: 278.0) were matched with controls (non-obese) in a 1:4 ratio for age, sex, and severity of CRC (metastasis vs. no metastasis). Linear regression and path analysis were used to compare outcomes between obese and non-obese patients. A total of 107,067 patients (53,376 males, 53,691 females) were included in the analysis, and 7.86% were obese. Results: The rates of postoperative infection, shock, bleeding, wound disruption, and digestive system complications were significantly different between the obese and non-obese groups. The obesity group had increased incidence of postoperative infection by 1.9% (∂P/∂X = 0.019), shock by 0.25% (∂P/∂X = 0.0025), postoperative bleeding by 0.5% (∂P/∂X = 0.005), wound disruption by 0.6% (∂P/∂X = 0.006), and digestive system complications by 1.35% (∂P/∂X = 0.0135). Path analysis showed that obesity group had higher in-hospital mortality through mentioned above five complications by 66.65 × 10−5%, length of hospital stay by 0.32 days, and total hospital charges by 2384 US dollars. Conclusions: Obesity increases the risk of postoperative complications in patients with CRC undergoing surgery. It also increased in-hospital mortality, length of hospital stay, and total hospital charges. Therefore, patients with obesity might require a higher level of preoperative interventions and complications monitoring to improve outcomes.

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Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Hyperosmolar Hyperglycemic State: Analysis of National Inpatient Sample

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.868 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A425-A426

Author(s):

Genaro Velazquez ◽

Hafeez Shaka ◽

Mukunthan Murthi ◽

Hernan Marcos-Abdala ◽

Sujitha Velagapudi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Septic Shock ◽

Hospital Mortality ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Hospital Charges ◽

Secondary Diagnosis ◽

Total Hospital ◽

Hospital Outcomes ◽

Hyperosmolar Hyperglycemic State

Abstract Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia and its negative prognostic impact on the morbidity and mortality of hospitalized patients has been well described. In patients with Hyperosmolar hyperglycemic state (HHS), mortality rates can reach up to 20% and poor outcomes have been reported in people with older age, presence of comorbid conditions and concurrent infections. However, the impact of atrial fibrillation on the hospital outcomes of patients admitted with HHS has not been well documented. Objective: We wanted to compare the outcomes for HHS hospitalizations for patients with and without Atrial fibrillation. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. About 42 740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of Atrial Fibrillation as secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total Hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders. Results: Out of the 42 740 hospitalizations with HHS, about 3 295 had Atrial Fibrillation. The in-hospital mortality for patients with HHS was 305 overall, out of which 60 patients had Atrial Fibrillation as secondary diagnosis. Compared with patients without Atrial Fibrillation, patients with Atrial Fibrillation had a similar in- hospital mortality (aOR 0.77, 95% CI 0.39–1.52, p=0.45) when adjusted for patient and hospital characteristics. Patients with HHS and Atrial Fibrillation had similar length of hospital stay, total Hospital charges, rate of Sepsis, Septic Shock, AKI, and ARF in comparison to patients without Atrial Fibrillation. Conclusion: Our study suggests that the presence of atrial fibrillation in hospitalized HHS patients is not associated with increased mortality or longer duration of hospital stay. This data is essential since it helps identify HHS patients with increased risk of complications. As previous reports have suggested that AF, especially of new onset in critically ill patients is a marker of increased disease severity, the lack of such impact in patients with HHS requires further studies.

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Outcomes in Hospitalizations for Patients Admitted With Hyperosmolar Hyperglycemic State and Obesity: Analysis of National Inpatient Sample

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.874 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A428-A429

Author(s):

Hafeez Shaka ◽

Genaro Velazquez ◽

Hernan Gerardo Marcos-Abdala ◽

Ehizogie Edigin ◽

Iriagbonse Asemota ◽

...

Keyword(s):

Septic Shock ◽

Hospital Mortality ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Adverse Outcomes ◽

Hospital Charges ◽

Obese Patients ◽

Secondary Diagnosis ◽

Total Hospital ◽

Significant Difference

Abstract Introduction: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) is a highly lethal disease with an estimated mortality rate of up to 20%. Although mortality has decreased in recent years, its incidence has increased in the setting of a higher prevalence of underlying conditions that have been previously well described, such as uncontrolled diabetes, Obesity, and a high-carbohydrate diet. All these comorbidities usually overlap with acute complications such as infections or dehydration, which incite the onset of HHS. Currently, limited literature exists for the role of obesity in mortality, hospital stay, and other adverse outcomes in patients with HHS. It is important to know which underlying conditions truly affect outcomes for patients being treated for this condition so further studies can be done, and treatment optimized. Objective: We aim to prove if obesity plays a role in increasing mortality and secondary adverse outcomes in patients with HHS compared to non-obese patients. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. 42,740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of Obesity as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders. Results: Out of the 42 740 hospitalizations with HHS, 9,630 had Obesity. The in-hospital mortality for patients with HHS was 45 overall, out of which 45 patients had Obesity as a secondary diagnosis. Compared with patients without Obesity, non-obese patients had similar in-hospital mortality (OR 0.77, 95% CI 0.39–1.52, p=0.45) when adjusted for patient and hospital characteristics. Patients with HHS and Obesity had similar lengths of hospital stay, total hospital charges, rate of Sepsis, Septic Shock, and ARF in comparison to patients without Obesity; however, non-obese patients had higher odds of developing AKI throughout hospitalization. Conclusion: Although it is known and described that being obese plays a significant role in the onset of diabetes, and consequently HHS, there is no statistically significant difference in mortality or most other adverse outcomes compared to patients that are not obese and develop HHS. Although being obese plays a major role in inciting HHS in the general population, there is no need for a different approach to treatment, and outcomes are similar to non-obese patients with HHS.

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The healthcare costs of antimicrobial resistance in Lebanon: a multi-centre prospective cohort study from the payer perspective

BMC Infectious Diseases ◽

10.1186/s12879-021-06084-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Katia Iskandar ◽

Christine Roques ◽

Souheil Hallit ◽

Rola Husni-Samaha ◽

Natalia Dirani ◽

...

Keyword(s):

Cohort Study ◽

Antimicrobial Resistance ◽

Hospital Mortality ◽

Hospital Stay ◽

Prospective Cohort ◽

Healthcare Costs ◽

Hospital Charges ◽

Resistant Bacteria ◽

Matched Cohort ◽

Payer Perspective

Abstract Background Our aim was to examine whether the length of stay, hospital charges and in-hospital mortality attributable to healthcare- and community-associated infections due to antimicrobial-resistant bacteria were higher compared with those due to susceptible bacteria in the Lebanese healthcare settings using different methodology of analysis from the payer perspective . Methods We performed a multi-centre prospective cohort study in ten hospitals across Lebanon. The sample size consisted of 1289 patients with documented healthcare-associated infection (HAI) or community-associated infection (CAI). We conducted three separate analysis to adjust for confounders and time-dependent bias: (1) Post-HAIs in which we included the excess LOS and hospital charges incurred after infection and (2) Matched cohort, in which we matched the patients based on propensity score estimates (3) The conventional method, in which we considered the entire hospital stay and allocated charges attributable to CAI. The linear regression models accounted for multiple confounders. Results HAIs and CAIs with resistant versus susceptible bacteria were associated with a significant excess length of hospital stay (2.69 days [95% CI,1.5–3.9]; p < 0.001) and (2.2 days [95% CI,1.2–3.3]; p < 0.001) and resulted in additional hospital charges ($1807 [95% CI, 1046–2569]; p < 0.001) and ($889 [95% CI, 378–1400]; p = 0.001) respectively. Compared with the post-HAIs analysis, the matched cohort method showed a reduction by 26 and 13% in hospital charges and LOS estimates respectively. Infections with resistant bacteria did not decrease the time to in-hospital mortality, for both healthcare- or community-associated infections. Resistant cases in the post-HAIs analysis showed a significantly higher risk of in-hospital mortality (odds ratio, 0.517 [95% CI, 0.327–0.820]; p = 0.05). Conclusion This is the first nationwide study that quantifies the healthcare costs of antimicrobial resistance in Lebanon. For cases with HAIs, matched cohort analysis showed more conservative estimates compared with post-HAIs method. The differences in estimates highlight the need for a unified methodology to estimate the burden of antimicrobial resistance in order to accurately advise health policy makers and prioritize resources expenditure.

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