Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center

BACKGROUND

Previous studies defining perioperative risk factors for allogeneic transfusion requirements in cardiac surgery were limited to highly selected cardiac surgery populations or were associated with high transfusion rates. The purpose of this study was to determine perioperative risk factors and create a formula to predict transfusion requirements for major cardiac surgical procedures in a center that practices a multimodality approach to blood conservation.

METHODS

We performed an observational study on 307 consecutive patients undergoing coronary artery bypass grafting, valve, and combined (coronary artery bypass grafting and valve) procedures. An equation was derived to estimate the risk of transfusion based on preoperative risk factors using multivariate analysis. In patients with a calculated probability of transfusion of at least 5%, intraoperative predictors of transfusion were identified by multivariate analysis.

RESULTS

Thirty-five patients (11%) required intraoperative or postoperative allogeneic transfusions. Preoperative factors as independent predictors for transfusions included red blood cell mass, type of operation, urgency of operation, number of diseased vessels, serum creatinine of at least 1.3 mg/dL, and preoperative prothrombin time. Intraoperative factors included cardiopulmonary bypass time, three or fewer bypass grafts, lesser volume of acute normovolemic hemodilution removed, and total crystalloid infusion of at least 2,500 mL. The derived formula was applied to a validation cohort of 246 patients, and the observed transfusion rates conformed well to the predicted risks.

CONCLUSIONS

A multimodality approach to blood conservation in cardiac surgery resulted in a low transfusion rate. Identifying patients' risks for transfusion should alter patient management perioperatively to decrease their transfusion rate and make more efficient use of blood resources.

Attitudes of Saudi male patients toward the replacement of teeth

STATEMENT AND PROBLEM: [corrected] The objective of tooth replacement is the restoration of esthetics and function. Patient perceptions of esthetic and functional needs may not match the dental professional's assessment of these needs.

PURPOSE

The objective of this study was to investigate the relationship between patient perceptions and professional assessments of prosthetic treatment needs in a population limited to Saudi men.

MATERIAL AND METHODS

The study population comprised 238 Saudi Arabian men between the ages of 16 and 77. Subjects were classified in accordance with 3 parameters: age (16-25, 26-35, 36-45, or >45 years); completed education (primary, high school, or higher education); and number of missing teeth (1, 2-3, 4-6, or >6). A structured interview was conducted and each subject was asked 3 closed-ended (yes/no) questions on tooth loss and its effects. The interview was followed by a dental examination in which each subject's dental status and normative treatment needs were assessed. Patient perception data were compared to professionally assessed need. Data were analyzed with McNemar's test (alpha=.05).

RESULTS

Overall, 82% (194) of subjects expressed the need to replace their missing teeth. Forty-four percent (105) believed that tooth loss negatively affected their appearance, and 63% (150) thought that tooth loss reduced their chewing efficiency. The discrepancy between perceived and professionally assessed need in regard to function was significant (P<.01).

CONCLUSION

Within the limitations of this study, subjective perceptions of esthetic and functional treatment needs were highly variable among the Saudi male patients evaluated. Patient perceptions could not be predictably estimated by professionally assessed clinical need.

The economics of public health: financing drug abuse treatment services

Drug abuse treatment financing exhibits a heterogeneous set of sources from federal, state, and local governments, as well as private sources from insurance, patient out-of-pocket, and charity. A public health model of drug abuse treatment is presented for a market that can be characterized by excess demand in many communities and an implied policy of rationing. According to best estimates, as many as 6.7 million individuals may need treatment, but only an estimated 1.5 million individuals actually participated in treatment episodes. Since, as demonstrated empirically, drug abuse treatment has a robust and positive social net benefit to society, it is perplexing that treatment financing stops with a rationing outcome that inhibits social welfare. The justification for public financing is centered on the external costs of drug addiction, but subsidization is grounded in the reality that a large number of addicted individuals do not have sufficient resources to pay for treatment out-of-pocket, nor do they have private insurance coverage. Social welfare losses are generated by financial arrangements that are inconsistent with rational budgeting theory and as such would lead to non-optimal organization and management of the drug abuse treatment system.

Exploring assistance in Sweden and the United States

PURPOSE

Few international comparisons of health services are performed using microlevel data. Using such data, this paper compares the need for and receipt of assistance with activities of daily living (ADLs) in comparable samples in the United States and Sweden, a country with a universal system of community-based services.

DESIGN AND METHODS

Data from national surveys of community residents completed at approximately the same time in each nation are used to create comparable measures of need and assistance. Descriptive and logistic regression analyses compare need and assistance patterns across the nations and identify individual factors that explain receipt of assistance and unmet needs.

RESULTS

Our results indicate that a simple story of greater use of paid formal services in Sweden and more unpaid informal use in the United States masks a more complex relationship. Assistance with ADLs seems to be more targeted in Sweden; narrow differences in assistance widen considerably when the analysis is limited to those reporting need.

IMPLICATIONS

Although these two different health systems result in similar levels of overall ADL assistance, a detailed microlevel comparison reveals key distinctions. Further microlevel comparisons of access, cost, and quality in cross-national data can further aid our understanding of the consequences of health policy.

Access by the unaccompanied under-16-year-old adolescent to general practice without parental consent

BACKGROUND

The views of primary health care providers concerning their willingness to consult with under-16-year-old adolescent patients without the presence of a parent or guardian are not well documented. Many young people believe they have to be aged over 16 years to see their general practitioner (GP) alone. Confidentiality is a major concern for young people. It is important that more is known about the willingness of GPs and practice nurses (PNs) to offer unaccompanied consultations without known parental consent.

AIM

To provide information on the willingness of GPs and PNs to consult with under-16-year-olds and whether policies exist in general practices to facilitate access by unaccompanied under-16-year-olds.

STUDY DESIGN

Cross-sectional study using a postal questionnaire.

SETTING

Seventeen general practices in the West of Cornwall.

METHOD

All GPs, PNs and receptionists were sent questionnaires.

RESULTS

The overall response rate was 79% (166/209 questionnaires). The majority of GPs and PNs (91%) were willing to consult with unaccompanied under-16-year-olds. A substantial number of primary health care team members are not aware of the existence of any practice policy on access. Only 41% of receptionists, 46% of PNs and 38% of GPs were aware of a definite practice policy.

CONCLUSIONS

GPs and PNs are willing to consult with under-16-year-olds without a parent or guardian being present. Many practices in this region do not appear to have policies in place to guide health professionals on under-16 access issues.

Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment

Although pain problems are prevalent in substance use disorder (SUD) patients, the special treatment needs of SUD patients with pain have not been investigated. This study examines the problems and behaviors associated with reported pain among veterans treated at eight opioid substitution treatment clinics. Patients reporting pain had more severe medical and psychiatric problems and greater health care utilization. Pain was associated with an increased propensity for misuse of substances with analgesic effects, suggesting that ongoing pain contributes to an altered and more severe pattern of drug-seeking behavior. Patients without pain rarely abused sedatives or opioid medication, indicating that misuse of these substances is unique to co-morbid pain and SUD patients. Patients reporting pain did not differ from patients without pain in use of heroin, alcohol, cocaine or in injection practices, demonstrating that they are truly SUD patients in need of SUD treatment. Pain complicates the treatment of SUD and should be addressed as an important co-morbidity during treatment.

Cyclic fluctuations in hospital bed occupancy in Roma (Italy): supply or demand driven?

The objective of this study was to assess hospital bed occupancy both by planned and unplanned cases, and to assess how supply and demand affect bed occupancy. Data was obtained from the Lazio Hospital Information System (HIS) dataset on all hospital discharges from July 1998 to June 2001. Using Diagnosis Related Groups (DRG) as the reason for hospital stay, admissions were classified into four categories: 'planned stay', 'presumed planned stay', 'presumed unplanned stay', and 'unplanned stay'. Time series analysis of daily bed occupancy by category of stay was performed. Generalized Additive Models (GAMs) were used to asses the effect of weekdays and holidays on bed occupancy. Fluctuations in daily occupancy were observed in all categories of stay-in general, bed occupancy decreased over weekends, on national holidays, and during the major holiday season of August. In comparison with unplanned stays, the largest fluctuations were observed for planned stays while presumed planned and unplanned stays showed lesser fluctuations. It is possible to distinguish planned and unplanned hospital stays by using DRG grouping. Cyclic rigidities in the supply of services rather than the availability of beds or demand for beds seem to dictate hospital use in Roma so that restrictions in services hamper any reallocation of beds for 'planned stay' when demand for 'unplanned stay' beds declines.

Evaluating emergency medical services: controlling the rising cost of saving lives

A combination of recent changes in the way Emergency Medical Services are reimbursed by Medicare for ambulance services and escalating costs have prompted many EMS providers to seek new ways to meet the needs of the communities they serve in a more cost-effective manner. This article reports one such study of a county in the Southeastern United States with a population of over 100,000 distributed over an area of 600 square miles. The study used industrial techniques, including a combination of historical data analysis and time studies, to recommend ways to cut costs without adversely affecting either the emergency coverage or patient case provided. Based on usage data, reducing the number of service units during time of least demand was suggested. The time studies indicated that it might be possible to combine some jobs (e.g. billing personnel and dispatchers), The usage data also showed that the existing geographical distribution of the units matched demand. The study demonstrated that industrial engineering techniques can be usefully employed in the evaluation of the efficiency and effectiveness of public services.

Collaboration and local networks for rural and remote primary mental healthcare in South Australia

This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.

La sostenibilidad del sistema hospitalario en Cataluña. El balance de una década

Concern about the viability of the hospital system has increased as demand has continued to grow and as the expected increase in public resources to meet this demand remains below requirements. The Central de Balances of CatSalut, which groups all the economic results of the Catalan Public Hospital Network (CPHN), has enabled determination of the relationship between activity and resources in the hospitals within the public sector from 1993 to 2000. We analyzed data from the Central de Balances to determine hospital functioning throughout the 1990s, paying special attention to the development of the hospital system's general productivity over this period. The annual accumulative growth in activity was 4.1%, that of expenses was 1.8% and that of revenues was 1.9%. Unitary cost in 2000 was 85.3% of the unitary cost in 1993.

[Orthodontic treatment needs and indications assessed with IONT]

The aim of this work was to determine the usefulness of the Index of Orthodontic Treatment Need (IOTN) in epidemiological studies undertaken to assess orthodontic treatment need of a given population, as well as in the process of defining indications to orthodontic treatment in individual cases with regard to objective treatment need and expressed demand for treatment. The correlation of the Aesthetic Component of IOTN (AC degree) with demand for treatment, usefulness of IOTN for screening studies, necessary modifications to make IOTN more acceptable to Polish orthodontists, and value of IOTN as a diagnostic and measuring tool for the assessment of orthodontic treatment need were addressed. The correlation between AC and demand for treatment, as well as the usefulness of IOTN in epidemiological studies were investigated with questionnaires and clinical examination using both components of IOTN (Figs. 1, 2, 3). The study group consisted of 264 schoolchildren aged 12 years. The results show that poor dental aesthetics is the main motivating factor to undertake orthodontic treatment (Tab. 1) and that demand for orthodontic treatment exceeds treatment need determined by IOTN (Tab. 2, 3). A regular distribution of AC degrees relative to the demand for treatment was obtained (Fig. 4) revealing the necessity to modify treatment need categories of this component in order to identify individuals with significant subjective treatment need. The modified aesthetic component would comprise the following treatment need categories: Grades (photographs) 1-2--"no demand for treatment"; 3-4--"borderline demand for treatment"; 5-10--"great demand for treatment". Excellent reproducibility of the Index (high values according to Kappa statistics), its universality, usefulness for various purposes, and simplicity in practice make the Index valuable for screening studies and assessment of treatment need in a given population. In order to test the reliability of the Dental Health Component of IOTN (the degree of conformity of this component with treatment tendencies among orthodontists), DHC criteria and subjective evaluation of treatment need were compared. This part of the study was carried out in a group of six orthodontists. 50 pairs of plaster casts covering a wide range of occlusal anomalies were analyzed. The subjective need for orthodontic treatment was stated for each case taking into account treatment priority and occlusal features determining treatment need. The results reveal a moderate conformity of DHC criteria with the orthodontist's opinion (Tab. 4 A, B) and a tendency among orthodontists to qualify for treatment also cases without treatment need according to IOTN recommendations. The discrepancy between the orthodontist's assessment of treatment need and DHC criteria applies mainly to cases with reverse overjet, front open bite, front or total crossbite and crowding in buccal segments of dental arches (Tab. 4 A, B). Matching the dental health component with opinions of Polish orthodontists requires shifting of some criteria from the moderate treatment need to the great treatment need category (Fig. 5).

La santé publique au Québec à l'aube du XXIe siècle

This paper summarises the status of public health in Quebec at the dawn of the 21st century. After introducing the current definition, the author lays out five basic functions of public health in Quebec: knowledge and surveillance of populations health and wellbeing, health protection; prevention of disease, trauma and social problems that influence health; health and wellbeing promotion; and service organization and evaluation. The organization of public health services is then described at the local level (CLSC), regional level (Public health units) and national level (Ministry, Public health directorate and National Institute of Public Health). Finally, the trends and priorities elaborated over the last ten years, as well as the National Public Health Program to be implemented over the next ten years are described.

[The audience of TV health programs]

The viewing figures of 36 unpaid TV health programs was assessed: the number of viewers, their socio-demographic status and interest in specific program. Between June 1998 and June 1999, non commercial TV health programs reached 0.7% to 7.6% TV audience, no more than 2,700.000 viewers per program. Programs broadcasted in evenings and winter time had more viewers. The audience consisted usually of: women, retired persons, rural inhabitants, persons with basic educational background. Pensioners were interested in every program, women in majority. Students, blue-collar workers and men were censorious and appreciated some programs only.

Psychotherapeutic interventions for adults with asthma

BACKGROUND

Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease.

OBJECTIVES

To assess the effectiveness of psychological interventions for adults with asthma.

SEARCH STRATEGY

The Cochrane Airways Group specialised register and PsycINFO were searched with pre-defined terms until September 2003.

SELECTION CRITERIA

Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

MAIN RESULTS

Twelve studies were included in the review, however study quality was poor and sample sizes were frequently small. No meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. Findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design.

REVIEWER'S CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Large, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

Oral health: perceptions of need in a rural Iowa county

Several studies have shown that oral health problems impact the quality of life of older adults. However, few data are available to describe the oral health status, barriers to care, and patterns of care for adults and older populations living in rural areas. The purpose of this study was to evaluate the perceived need for treatment of oral health problems by adult residents in a rural county in Iowa. The oral health component was part of a larger longitudinal health study of the residents. The sample was stratified into three groups by residence, that is, farm households, rural non-farm households and town households. The sample was subsequently post-stratified by gender and age group into young elderly, 65-74 years old, and old elderly, 75 years and older. Dentition status varied according to age and was related to the perception of treatment needs. Edentulous persons had fewer perceived treatment needs and utilized a dentist less frequently. Place of residence, education, and marital status were not associated with the subjects' perceived problems with eating and chewing. However, persons with difficulty chewing were more likely to have some missing upper teeth, have a perceived need to have denture work, and have smoked for a number of years. The results suggest that this rural population is retaining more teeth and consequently may need and may seek dental services more often than previous more edentulous cohorts.

Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A

Object. The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection.

Methods. A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities.

The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A—injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age.

Conclusions. Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.

Does diagnosis determine delivery? The Islington study of older people's needs and health care costs

BACKGROUND

Little is known about the factors associated with the receipt of care by older people. This study investigates the use. costs and factors associated with service usage among people aged 65 or older living in inner London.

METHOD

A community-based survey, using questionnaires, examined psychiatric and physical morbidity, formal and informal care. The relationships between demographic, pathological features and the costs of health and social care were explored using multivariate regression.

RESULTS

A total of 1085 people were interviewed at home of these 18% did not receive any service at all. The total cost of services per week for people with dementia was pound 109, with activity limitation pound 14 and with depression pound 12. The greatest effect of physical limitation was on the receipt of social care. Dementia had the strongest effect on receipt of social care services. Depression increased health care costs to a much greater degree than social care costs. Despite presenting to services, black elders received significantly less health care than other people with the same needs. Older people living alone were more likely to receive social care support and appeared less likely to use health services.

CONCLUSIONS

Physical dependency significantly affects both health and social care costs. Increasing cognitive impairment mainly leads to increasing social care costs. Overall costs are increased by physical dependency, dementia, depression, subjective health problems, living alone and are negatively affected by being black.

Comparison of rural and urban users and non-users of home care in Canada

INTRODUCTION

Geography is considered a determinant of health because people living in rural and remote areas, compared with those in urban areas, have poorer health status and more difficulty accessing health care.

PURPOSE

To examine the characteristics associated with the use of publicly funded home care services among rural and urban Canadians 18 years of age and over.

METHODS

The Andersen and Newman Behavioural Model of Health Services Use guided the selection of variables, analyses and interpretation of the findings. Descriptive, correlation and multiple logistic regression analyses were completed on 2 cross-sectional cycles of Statistics Canada's National Population Health Surveys.

RESULTS AND CONCLUSION

This research revealed that rural residents are increasingly less likely to receive personal care assistance, and rural home care users appear to have more resources (e.g., higher levels of education, sense of coherence) that likely influence their ability to access and receive home care services, than their urban counterparts. Rural residents without these resources may be less likely to receive home care services.

Gender differences in health information needs and decisional preferences in patients recovering from an acute ischemic coronary event

OBJECTIVE

This study examined gender differences in health information needs and decisional preferences after an acute ischemic coronary event (ICE).

METHODS

Patients with ICE, recruited in 12 coronary intensive care units, completed a questionnaire on demographic, disease-related, and psychosocial topics. Six and 12 months later, they completed mailed follow-up questionnaires.

RESULTS

Nine hundred six patients completed the baseline questionnaire, 541 (69%) completed the 6-month questionnaire, and 522 (64%) completed the 12-month questionnaire after hospital discharge. Men reported significantly more information received and greater satisfaction with healthcare practitioners meeting their information needs. Women wanted more information than men concerning angina and hypertension. Men wanted more information about sexual function and reported receiving more information about the role of each doctor, test results, treatments, cardiac rehabilitation, and how their families could support their lifestyle changes. Patients who reported receiving more information reported less depressive symptomatology and greater self-efficacy, healthcare satisfaction, and preventive health behaviors. Although most patients of both sexes preferred a shared decision-making role with their physician, the majority felt their doctor had made the main decisions.

CONCLUSIONS

Patients after ICE, especially women, reported receiving much less information than they wanted from all health professionals. Most patients wanted a shared or autonomous treatment decision-making role with their doctor, but only a minority experienced this. Clinicians must do better, because meeting patients' information needs and respecting their decisional preferences are shown to be associated with better self-efficacy, satisfaction, and health-promoting behavior.

The dermatology workforce shortage

BACKGROUND

While many dermatology workforce projections over the past two decades forecasted an impending oversupply, more recent reports have begun to suggest a shortage of dermatologic services.

METHODS

Anonymous surveys administered to practicing dermatologists and to recent training graduates were examined for surrogate indicators of the supply and demand for dermatologic services.

RESULTS

The mean wait time for new patient appointments with dermatologists was 36 calendar days, but ranged widely based on location (means ranged from 9-120 days by state). About half (49%) of practicing dermatologists feel that they need more dermatologists in their communities, while only 20% describe the local supply as too high. The reported need for medical and general dermatologists is far more acute than for dermatologic subspecialists. Many practices (33%) are looking for new associates, and not surprisingly, most new graduates entering the workforce over the past 4 years (86-93%) do not describe any difficulty finding desirable positions. Fewer than 10% of recent graduates are dissatisfied with their current jobs.

CONCLUSION

Based on survey data examining wait times, physician perception, use of physician extenders, searches for new employees, and experience of recent graduates entering the workforce, it appears there is an inadequate supply of dermatologists to meet the demand for services.

Evaluation of the masticatory system condition with respect to the need for prosthetic treatment in the population of 35-44-year-olds from the Lublin Region

An epidemiological study was carried out on the population of 59 subjects aged 35-4 (30 women, 29 men) living in Lublin. An evaluation of dentition status and degree of provision for prosthetic needs was done. We observed a remarkable frequency of dental caries, a large percentage of subjects with missing or damaged teeth (76.27%), and inadequate advancement of prosthetic treatment in 62.71% of subjects. Greater care for prosthetic treatment was observed among women than among men. Gaps within the maxilla were more often protected than those within the mandible.