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Lin CW, Huang HY, Guo JH, Chen WL, Shih HM, Chu HT, Wang CC, Hsu TY. Does Weekends Effect Exist in Asia? Analysis of Endovascular Thrombectomy for Acute Ischemic Stroke in A Medical Center. Curr Neurovasc Res 2022; 19:225-231. [PMID: 35894472 PMCID: PMC9900696 DOI: 10.2174/1567202619666220727094020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Discussing the quality measurements based on interrupted time series in ischemic stroke, delays are often attributed to weekends effect. This study compared the metrics and outcomes of emergent endovascular thrombectomy (EST) during working hours versus non-working hours in the emergency department of an Asian medical center. METHODS A total of 297 patients who underwent EST between January 2015 and December 2018 were retrospectively included, with 52.5% of patients presenting during working hours and 47.5% presenting during nights, weekends, or holidays. RESULTS Patients with diabetes were more in non-working hours than in working hours (53.9% vs. 41.0%; p=0.026). It took longer during nonworking hours than working hours in door-to -image times (13 min vs. 12 min; p=0.04) and door-to-groin puncture times (median: 112 min vs. 104 min; p=0.042). Significant statistical differences were not observed between the two groups in neurological outcomes, including successful reperfusion and complications such as intracranial hemorrhage and mortality. However, the change in National Institute of Health Stroke Scale (NIHSS) scores in 24 hours was better in the working-hour group than in the nonworking-hour group (4 vs. 2; p=0.058). CONCLUSION This study revealed that nonworking-hour effects truly exist in patients who received EST. Although delays in door-to-groin puncture times were noticed during nonworking hours, significant differences in neurological functions and mortality were not observed between working and non-working hours. Nevertheless, methods to improve the process during non-working hours should be explored in the future.
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Affiliation(s)
- Chia-Wei Lin
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Hung-Yu Huang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jeng-Hung Guo
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan;,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Wei-Laing Chen
- Department of Neuroradiology, China Medical University Hospital, Taichung, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Department of Public Health, China Medical University, Taipei, Taiwan
| | - Hsueh-Ting Chu
- Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Charles C.N. Wang
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan;,Center for Precision Health Research, Asia University, Taichung, Taiwan,Address correspondence to these authors at the Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan and Center for Precision Health Research, Asia University, Taichung, Taiwan; E-mails: ;
| | - Tai-Yi Hsu
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
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Choi J, Mulaney B, Laohavinij W, Trimble R, Tennakoon L, Spain DA, Salomon JA, Goldhaber-Fiebert JD, Forrester JD. Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups. J Trauma Acute Care Surg 2021; 90:451-458. [PMID: 33559982 DOI: 10.1097/ta.0000000000003021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE Economic/decision, level II.
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Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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Watson SI, Chen YF, Bion JF, Aldridge CP, Girling A, Lilford RJ. Protocol for the health economic evaluation of increasing the weekend specialist to patient ratio in hospitals in England. BMJ Open 2018; 8:e015561. [PMID: 29476025 PMCID: PMC5855484 DOI: 10.1136/bmjopen-2016-015561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION This protocol concerns the evaluation of increased specialist staffing at weekends in hospitals in England. Seven-day health services are a key policy for the UK government and other health systems trying to improve use of infrastructure and resources. A particular motivation for the 7-day policy has been the observed increase in the risk of death associated with weekend admission, which has been attributed to fewer hospital specialists being available at weekends. However, the causes of the weekend effect have not been adequately characterised; many of the excess deaths associated with the 'weekend effect' may not be preventable, and the presumed benefits of improved specialist cover might be offset by the cost of implementation. METHODS/DESIGN The Bayesian-founded method we propose will consist of four major steps. First, the development of a qualitative causal model. Specialist presence can affect multiple, interacting causal processes. One or more models will be developed from the results of an expert elicitation workshop and probabilities elicited for each model and relevant model parameters. Second, systematic review of the literature. The model from the first step will provide search limits for a review to identify relevant studies. Third, a statistical model for the effects of specialist presence on care quality and patient outcomes. Fourth, valuation of outcomes. The expected net benefits of different levels of specialist intensity will then be evaluated with respect to the posterior distributions of the parameters. ETHICS AND DISSEMINATION The study was approved by the Review Subcommittee of the South West Wales REC on 11 November 2013. Informed consent was not required for accessing anonymised patient case records from which patient identifiers had been removed. The findings of this study will be published in peer-reviewed journals; the outputs from this research will also form part of the project report to the HS&DR Programme Board.
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Affiliation(s)
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian F Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Cassie P Aldridge
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Division of Health and Population Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Cook WA, Morrison ML, Eaton LH, Theodore BR, Doorenbos AZ. Quantity and Quality of Economic Evaluations in U.S. Nursing Research, 1997-2015: A Systematic Review. Nurs Res 2017; 66:28-39. [PMID: 27893648 PMCID: PMC5159252 DOI: 10.1097/nnr.0000000000000188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The United States has a complex healthcare system that is undergoing substantial reformations. There is a need for high-quality, economic evaluations of nursing practice. An updated review of completed economic evaluations relevant to the field of nursing within the U.S. healthcare system is timely and needed. OBJECTIVES The purpose of this study was to evaluate and describe the quantity and quality of economic evaluations in nursing-relevant research performed in the United States between 1997 and 2015. METHODS Four databases were searched. Titles, abstracts, and full-text content were reviewed to identify studies that analyzed both costs and outcomes, relevant to nursing, performed in the United States, and used the quality-adjusted life year to measure effectiveness. For included studies, data were extracted from full-text articles using criteria from U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. RESULTS Twenty-eight studies met the inclusion criteria. Most (n = 25, 89%) were published in the last decade of the analysis, from 2006 to 2015. Assessment of quality, based on selected items from the panel guidelines, found that the evaluations did not consistently use the recommended societal perspective, use multiple resource utilization categories, use constant dollars, discount future costs and outcomes, use a lifetime horizon, or include an indication of uncertainty in results. The only resource utilization category consistently included across studies was healthcare resources. DISCUSSION Only 28 nursing-related studies meeting the inclusion criteria were identified as meeting robust health economic evaluation methodological criteria, and most did not include all important guideline items. Despite increases in absolute numbers of published studies over the past decade, economic evaluation has been underutilized in U.S. nursing-relevant research in the past two decades.
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Affiliation(s)
- Wendy A Cook
- Wendy A. Cook, PhD, RN, CCNS, is U.S. Navy Nurse Corps Nurse Scientist, Naval Medical Center San Diego, California, and Affiliate Assistant Professor, School of Nursing, University of Washington, Seattle. Megan L. Morrison, PhD, ARNP, FNP-BC, ACHPN, is Palliative and Supportive Care Attending Nurse Practitioner, Northwest Hospital and Medical Center, Seattle, Washington. Linda H. Eaton, PhD, RN, AOCN, is Project Director, Pain and Symptom Management in Rural Communities, School of Nursing, University of Washington, Seattle, and Post-Doctoral Research Fellow, University of Utah College of Nursing, Salt Lake City. Brian R. Theodore, PhD, is Research Assistant Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle. Ardith Z. Doorenbos, PhD, RN, FAAN, is Professor, School of Nursing and School of Medicine, University of Washington, Seattle
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Lopatina E, Donald F, DiCenso A, Martin-Misener R, Kilpatrick K, Bryant-Lukosius D, Carter N, Reid K, Marshall DA. Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review. Int J Nurs Stud 2017; 72:71-82. [PMID: 28500955 DOI: 10.1016/j.ijnurstu.2017.04.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/21/2017] [Accepted: 04/28/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. OBJECTIVE To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. METHODS Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. RESULTS The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. CONCLUSION Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.
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Affiliation(s)
- Elena Lopatina
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3C60, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, B3H 4R2, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montréal, Research Centre Hôpital Maisonneuve-Rosemont, CSA - RC - Aile bleue - Room F121, 5415 boul. l'Assomption, Montréal, QC, H1T 2M4, Canada.
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, L8S 4L8, Canada.
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28H, Hamilton, ON, L8S 4L8, Canada.
| | - Kim Reid
- KJResearch, Rosemere, QC, Canada.
| | - Deborah A Marshall
- Department of Community Health Sciences and Faculty of Medicine, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C58, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Economic evaluation of registered nurse tenure on nursing home resident outcomes. Appl Nurs Res 2016; 29:89-95. [PMID: 26856495 DOI: 10.1016/j.apnr.2015.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 04/20/2015] [Accepted: 05/09/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Little is known about the economic implications of nursing home (NH) registered nurse (RN) tenure on resident outcomes. This study evaluated the cost-effectiveness of two nurse workforce scenarios focusing on RN tenure (high versus low), and the associated transfers from NH to the hospital. METHODS A decision tree was constructed to compare the incremental costs and effects of RN tenure scenarios on NH resident transfers to the hospital under two NH staffing scenarios: high versus low levels of RN tenure. Three outcomes were modeled: 1) dollars per hospitalization avoided, 2) dollars per hospitalization and death avoided, and 3) dollars per death avoided. RESULTS The total costs of care for the low tenure scenario were $34,108 per month compared to the high tenure scenario at $29,442 per month. Effectiveness of the high tenure was greater across all 3 outcomes (incremental effectiveness ranged from 0.925 to 0.974 depending on outcome), indicating that high tenure was the dominant strategy (that is less costly and more effective). CONCLUSIONS Higher RN tenure was a dominant strategy across the 3 outcomes. This was a fairly robust finding despite the variations in the model and uncertainty in the input parameters. Aligning quality outcomes with cost effectiveness is imperative to driving the direction of health policy in the United States. Better prevention of hospitalizations by having an experienced RN workforce will not only improve resident quality of care but will allow NHs to realize the value of retaining a skilled workforce.
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Hodgkinson B, Haesler EJ, Nay R, O'Donnell MH, McAuliffe LP. Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes. Cochrane Database Syst Rev 2011:CD006563. [PMID: 21678358 DOI: 10.1002/14651858.cd006563.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging. OBJECTIVES To identify which staffing models are associated with the best patient and staff outcomes. SEARCH STRATEGY We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles. SELECTION CRITERIA This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes. DATA COLLECTION AND ANALYSIS Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC. MAIN RESULTS We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited. AUTHORS' CONCLUSIONS Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.
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Goryakin Y, Griffiths P, Maben J. Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review. Int J Nurs Stud 2011; 48:501-12. [DOI: 10.1016/j.ijnurstu.2010.07.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 07/15/2010] [Accepted: 07/26/2010] [Indexed: 10/19/2022]
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Abstract
Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.
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