Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

OBJECTIVE

To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays.

PARTICIPANTS

Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients.

RESULTS

We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)).

CONCLUSIONS

The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments

OBJECTIVES

Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease.

METHODS

A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing.

RESULTS

The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6).

CONCLUSIONS

This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

Adaptation of time‐driven activity‐based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department

Objectives

The aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time.

Methods

TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field.

Results

Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals.

Conclusions

The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.

Cost-effectiveness of FreeO2 in patients with chronic obstructive pulmonary disease hospitalised for acute exacerbations: analysis of a pilot study in Quebec

OBJECTIVE

Conduct a cost-effectiveness analysis of FreeO₂ technology versus manual oxygen-titration technology for patients with chronic obstructive pulmonary disease (COPD) hospitalised for acute exacerbations.

SETTING

Tertiary acute care hospital in Quebec, Canada.

PARTICIPANTS

47 patients with COPD hospitalised for acute exacerbations.

INTERVENTION

An automated oxygen-titration and oxygen-weaning technology.

METHODS AND OUTCOMES

The costs for hospitalisation and follow-up for 180 days were calculated using a microcosting approach and included the cost of FreeO₂ technology. Incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap resampling with 5000 replications. The main effect variable was the percentage of time spent at the target oxygen saturation (SpO₂). The other two effect variables were the time spent in hyperoxia (target SpO₂+5%) and in severe hypoxaemia (SpO₂ <85%). The resamplings were based on data from a randomised controlled trial with 47 patients with COPD hospitalised for acute exacerbations.

RESULTS

FreeO₂ generated savings of 20.7% of the per-patient costs at 180 days (ie, -$C2959.71). This decrease is nevertheless not significant at the 95% threshold (P=0.13), but the effect variables all improved (P<0.001). The improvement in the time spent at the target SpO₂ was 56.3%. The ICERs indicate that FreeO₂ technology is more cost-effective than manual oxygen titration with a savings of -$C96.91 per percentage point of time spent at the target SpO₂ (95% CI -301.26 to 116.96).

CONCLUSION

FreeO₂ technology could significantly enhance the efficiency of the health system by reducing per-patient costs at 180 days. A study with a larger patient sample needs to be carried out to confirm these preliminary results.

TRIAL REGISTRATION NUMBER

NCT01393015; Post-results.

[Cerebral vasculopathy in children with sickle cell disease: Key issues and the latest data]

Cerebral vasculopathy is a common and severe complication of sickle cell disease in children. The pathophysiology consists of progressive damage to the basal intracranial arteries and cerebral microcirculation, while chronic anemia worsens exposure to cerebral hypoxia. It results in stroke and subclinical or poorly symptomatic ischemic lesions. Many clinical, biological, and radiological risk factors have been identified. The prevention strategy through systematic transcranial Doppler screening of large-vessel vasculopathy has revolutionized the management of this disease and has greatly decreased the risk of developing stroke. MRI-MRA is a complementary diagnostic tool for anatomical analysis of parenchymal and vascular lesions, which is used for chronic disease monitoring or in the context of an acute neurological event. New exploration opportunities are offered by submandibular Doppler sonography and indirect evaluation methods of cerebral oxygenation and perfusion. If chronic blood transfusion therapy is used to prevent the occurrence and recurrence of cerebral complications of sickle cell disease, only allogeneic hematopoietic stem cell transplantation can safely and definitively stop the transfusion program. It should therefore be proposed early, before irreversible cerebral or vascular lesions occur. Hydroxycarbamide treatment has recently emerged as a potential substitute for chronic transfusions for the maintenance of transcranial Doppler velocities, but only after an initial treatment by transfusions and provided there is close follow-up. In the long run, cerebral vascular damage can cause progressive cognitive impairment and disability, even in children without radiologically identified lesions, indicating the importance of systematic and repeated neuropsychological testing.

Plasmodial aspartyl-tRNA synthetases and peculiarities in Plasmodium falciparum

Distinctive features of aspartyl-transfer RNA (tRNA) synthetases (AspRS) from the protozoan Plasmodium genus are described. These apicomplexan AspRSs contain 29-31 amino acid insertions in their anticodon binding domains, a remarkably long N-terminal appendix that varies in size from 110 to 165 amino acids and two potential initiation codons. This article focuses on the atypical functional and structural properties of Plasmodium falciparum cytosolic AspRS, the causative parasite of human malaria. This species encodes a 626 or 577 amino acids AspRS depending on whether initiation starts on the first or second in-frame initiation codon. The longer protein has poor solubility and a propensity to aggregate. Production of the short version was favored as shown by the comparison of the recombinant protein with endogenous AspRS. Comparison of the tRNA aminoacylation activity of wild-type and mutant parasite AspRSs with those of yeast and human AspRSs revealed unique properties. The N-terminal extension contains a motif that provides unexpectedly strong RNA binding to plasmodial AspRS. Furthermore, experiments demonstrated the requirement of the plasmodial insertion for AspRS dimerization and, therefore, tRNA aminoacylation and other putative functions. Implications for the parasite biology are proposed. These data provide a robust background for unraveling the precise functional properties of the parasite AspRS and for developing novel lead compounds against malaria, targeting its idiosyncratic domains.

Social determinants of access to reference care centres for patients with colorectal cancer – A multilevel analysis

BACKGROUND

Although social disparities in survival for patients with cancer are documented in an increasing number of papers, knowledge on the underlying mechanisms concerning screening, diagnosis, treatment or follow-up, is relatively poor. Our study was aimed at investigating the social determinants of access to reference cancer care centres for surgery for colorectal cancer in France.

METHODS

Retrospective analysis was conducted on population-based data from a specialised cancer registry (County of Calvados, France). The population consisted of 5156 patients with surgical treatment for colorectal cancer recorded between January 1st 1981 and December 31st 2000.

RESULTS

The probability of being cared for in a reference care centre was 1.3-fold lower for people living in a deprived district (mean income < 15000 euros) and 3-fold lower for people living in a district where more than 7% of houses were devoid of bath and shower in comparison with districts where this rate was under 2%. After adjustment for distance from reference care centre, the probability of being cared for in a reference care centre was still over one third lower for people living in a district with more than 7% of houses devoid of bath and shower. Social disparities in management of patients with colorectal cancer have increased in the last decade. The reduction of access to reference care with distance was stronger in elderly patients.

CONCLUSIONS

There is a social and geographical determination of type of treatment centre for care management of colorectal cancer in France. Special attention needs to be paid to the high quality of care management in non-specialised care centres in order to avoid an increased social gradient in cancer mortality in France.

Foraging methods can affect patch choice: an experimental study in Mallard (Anas platyrhynchos)

Animals can adapt to changes in feeding conditions by switching between foraging methods. Dabbling ducks use different foraging methods, including dabbling in deep water with the head and neck submerged, and grubbing in the mud (or shallow water) where the eyes are above the surface, so the bird can visually monitor its environment while foraging. Deep foraging is considered to provide lower intake rates and to have high associated costs, such as predation risk, compared to shallow foraging. Ducks should thus prefer shallow foraging and switch to deeper methods when feeding conditions deteriorate. We conducted a set of experiments with Mallard to assess the importance of intake rate as a cue to choose between patches associated with different foraging methods, and evaluate the influence of food depletion on the decision to switch between methods. When 50 g of wheat were presented in two patches, one at a depth of 5 cm and one at 35 cm, most of the foraging was in the shallow area. Reducing food abundance to 10 g in the shallow area led to an increase in deep foraging, although the birds still preferred the shallow area at the beginning of the tests despite the fact that it did not provide a higher intake rate. This area was used until complete depletion, and birds did not turn to deep foraging before ensuring that the shallow patch was empty. These results show that food depletion affects the choice between feeding patches hence foraging method. However the value of intake rate is not the main cue for decision, rather the birds appear to choose between patches with different methods on account of their respective costs.

Nitric oxide production during endotoxin-induced mastitis in the cow

Nitric oxide production was measured during endotoxin-induced mastitis. One hour after morning milking, the right hind quarters of 15 cows were infused with saline containing Escherichia coli endotoxin. Left hind control quarters were infused with saline only. At varying intervals before and after infusion, diagnostic markers of mastitis were recorded and nitric oxide production was evaluated by measuring nitrite plus nitrate levels in milk. In endotoxin-infused quarters, a significant increase in nitrite plus nitrate concentrations was observed 3 h postinfusion; concentrations decreased to preinfusion levels within 48 h. This change indicates that significant amounts of nitric oxide are released during endotoxin-induced mastitis. At 3 different time points, somatic cells were harvested from milk samples, plated, and maintained in culture for 24 h. The concentration of nitrite plus nitrate in medium from cells harvested 12 h postinfusion was increased, suggesting that nitric oxide is released, at least in part, by milk somatic cells. In a second set of experiments, we evaluated nitric oxide production when animals were infused with endotoxin and aminoguanidine, a specific inhibitor of the inducible form of nitric oxide synthase. In cows treated with aminoguanidine, the increase in nitrite plus nitrate observed after endotoxin infusion was prevented. These results suggest that nitric oxide production during endotoxin-induced mastitis resulted from the activity of the inducible form of nitric oxide synthase. They also support a possible involvement for nitric oxide in the inflammatory reaction observed during mastitis.

Regulation of CCAAT/enhancer binding protein isoforms by serum and glucocorticoids in the rat intestinal epithelial crypt cell line IEC-6

Members of the CCAAT/enhancer binding protein (C/EBP) gene family are expressed in murine intestine. However, little is known about their regulation in intestinal epithelial cells. In an attempt to determine regulatory mechanisms involved in their expression, we examined C/EBP alpha, beta, and delta isoform expression in response to serum and glucocorticoids in the rat intestinal epithelial crypt-derived cell line IEC-6, by Northern blot, transcription run-on assays, indirect immunofluorescence, Western blot, and electrophoretic mobility shift assays. Serum leads to rapid and transient increases in C/EBP alpha and beta mRNA and protein levels by posttranscriptional regulatory mechanisms, without affecting transcriptional initiation. However, C/EBP-specific DNA binding capacity is not affected by serum. Whereas C/EBP alpha expression is not regulated by glucocorticoids, C/EBP beta and delta mRNA and protein levels are rapidly induced. These inductions result from both increased transcription rates and posttranscriptional regulatory mechanisms as well. Moreover, C/EBP beta and delta containing DNA binding complexes are increased by glucocorticoids as determined by supershift assays, in contrast to C/EBP alpha containing complexes. Immunofluorescence studies show cytoplasmic and nuclear localization for C/EBP alpha, in contrast to a restricted nuclear localization for both C/EBP beta and C/EBP delta. These results confirm C/EBP isoforms expression in intestinal epithelial cells. Differential regulation by serum and glucocorticoids as well as different localization of three C/EBP isoforms suggest a role for this class of transcription factors in the control of gene expression in intestinal epithelial cells.

Differential expression of fos and jun family members during murine postnatal intestinal development

We have examined the patterns of expression of members of the fos and jun families of transcription factors during murine postnatal intestinal development. Northern analysis showed increases in fosB, c-fos, and junB mRNA levels in both proximal jejunum and colon. These increases coincide with weaning a period of major changes in intestinal cell proliferation and migration. Administration of dexamethasone to suckling mice resulted in transient induction of c-fos mRNA levels in all gut segments. Thus, modifications in expression of certain members of the fos and jun families in vivo correlate with major maturational changes during murine intestinal development and support a role for these transcription factors in the regulation of intestinal functions.

CCAAT/enhancer binding protein isoforms expression in the colon of neonatal mice

Development of murine proximal colon follows a complex pattern of morphological and functional differentiation. Molecular mechanisms and factors responsible for colon-specific gene expression remain to be established. In an attempt to identify some of these factors, we examined the expression of the alpha, beta, and delta isoforms of the CCAAT/enhancer binding protein (C/EBP) transcription factor gene family during murine colon development. Whereas C/EBP alpha mRNA levels are reduced during the third post-natal week, C/EBP alpha 42 and 30 kD proteins levels decrease between post-natal days 8 and 21. C/EBP beta mRNA levels increase between post-natal days 4 and 8 and remain constant subsequently, in contrast to a decrease in C/EBP beta protein levels between post-natal days 11 and 15. C/EBP delta mRNA levels increase gradually while C/EBP delta protein levels show variations during post-natal development. Changes in C/EBP DNA binding activity coincides with modifications in C/EBP isoforms expression. By indirect immunofluorescence, we show restriction of C/EBP alpha expression to differentiated surface epithelial cells during crypt formation. C/EBP alpha is predominantly nuclear with some cytoplasmic staining at all developmental stages. C/EBP beta and delta are both predominantly nuclear in crypt and differentiated surface epithelial cells, as well as in various cells of the lamina propria and muscular layers. Thus, specific C/EBP isoforms are differentially regulated during murine colon post-natal development. Differential C/EBP isoforms pattern of expression suggests a role for these transcription factors in colon-specific gene expression during development.

Determination of the intrinsic Michaelis constant of immobilized alpha-chymotrypsin

The Michaelis constant of alpha-chymotrypsin, immobilized on a glutaraldehyde-activated silicate support, for N-glutaryl-L-phenylalanine-p-nitroanilide was determined and was found to be identical with that of the enzyme in solution. The influence of intraparticular diffusion was taken into account by immobilizing different amounts of enzyme, thus changing the magnitude of diffusional constraints and extrapolating apparent Michaelis constants, determined for each amount of immobilized enzyme, to zero diffusional constraints. The possible effect of the immobilized enzyme distribution inside the porous matrix was investigated through numerical simulations.

[The young homeless of Montreal: a longitudinal study]

A transverse survey conducted in 142 young homeless (age: 18-30) shows that they mainly come from broken families where alcoholism, violence and mental illness hold an important place. Regarding work, the majority of the surveyed homeless have not worked more than 24 months in all their life and have nearly continuously been on welfare; those who had jobs lost them much more because of their alcohol or drug use and their problems of interpersonal relationships than because of unemployment. On a personal level, these young adults are particularly battling against two major problems: alcoholism and drug addiction, and mental illness. Although 23% of the surveyed subjects have already been hospitalized in psychiatry, the majority of these young homeless have never received any psychiatric care. Nevertheless, they show mental health problems which are often mistakenly dismissed as the effects of alcoholism or chronic drug abuse. The authors believe that means of detection and adequate treatment must be developed for this growing population instead of thinking of social measures which would only give the young homeless a meal and protection from the elements.