[Frequency and characteristics of interventions by community paramedics on people in need of care : Analysis of 2,410 deployment protocols for people aged 65+ years]

BACKGROUND

The aim of this study was to obtain a differentiated view of interventions delivered by community paramedics (Gemeindenotfallsanitäter, G‑NFS) in older people in need of care living in nursing homes and at home.

MATERIALS AND METHODS

A retrospective analysis of G‑NFS documentation from 2021 with a focus on patients aged ≥65 years was performed. Data were grouped into callouts to nursing homes or private homes. Interventions, urgency, transport, and further recommendations were analyzed descriptively.

RESULTS

Of 5,900 G-NFS protocols, 43.0% (n = 2,410) were related to elderly people (mean age 80.8 years, 49.7% female). A total of 20.6% of these callouts involved nursing home residents, 38.4% (n = 926) were homecare patients, and 41% (n = 988) of callouts were to persons who did not rely on care. No specific interventions except advice were given to 48.4% of nursing home residents, and to even 82.1% of those in homecare and 83.7% of those without care needs. About 60% of the G‑NFS interventions were classified as non-urgent. Transport was waived for 63.1% of nursing home residents, for 58.1% in homecare, and for 60.6% of persons without care needs. A visit to the emergency department was recommended to 29.4% of nursing home residents, 37.6% of homecare patients, and 33.6% of persons without need of care. Measures related to urine catheters were documented much more often in nursing homes (38.5%) than in patients in homecare (15.1%) or without need of care (9.3%).

CONCLUSION

Community paramedics perform primary care tasks and can contribute to a reduction in unnecessary transport. It should be discussed whether the emergency medical service is responsible for such interventions and how older people in need of care can be cared for according to their needs in the future.

Arterial insufficiencies: Central retinal artery occlusion

Central retinal artery occlusion (CRAO) is a relatively rare emergent condition of the eye resulting in sudden painless vision loss. This vision loss is usually dramatic and permanent, and the prognosis for visual recovery is poor. A wide variety of treatment modalities have been tried over the last 100 years with little to no success, with the exception of hyperbaric oxygen therapy. The optimum number of treatments will vary depending on the severity and duration of the patient's symptoms and the degree of response to treatment. The majority of patients will stabilize within a few days after symptom onset. Utilization review is recommended for patients treated for more than three days after clinical plateau.

Cervical cancer screening utilization and predictors among eligible women in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Despite a remarkable progress in the reduction of global rate of maternal mortality, cervical cancer has been identified as the leading cause of maternal morbidity and mortality, particularly in sub-Saharan African countries. The uptake of cervical cancer screening service has been consistently shown to be effective in reducing the incidence rate and mortality from cervical cancer. Despite this, there are limited studies in Ethiopia that were conducted to assess the uptake of cervical cancer screening and its predictors, and these studies showed inconsistent and inconclusive findings. Therefore, this systematic review and meta-analysis was conducted to estimate the pooled cervical cancer screening utilization and its predictors among eligible women in Ethiopia.

METHODS AND FINDINGS

Databases like PubMed, Web of Science, SCOPUS, CINAHL, Psychinfo, Google Scholar, Science Direct, and the Cochrane Library were systematically searched. All observational studies reporting cervical cancer screening utilization and/ or its predictors in Ethiopia were included. Two authors independently extracted all necessary data using a standardized data extraction format. Quality assessment criteria for prevalence studies were adapted from the Newcastle Ottawa quality assessment scale. The Cochrane Q test statistics and I2 test were used to assess the heterogeneity of studies. A random effects model of analysis was used to estimate the pooled prevalence of cervical cancer screening utilization and factors associated with it with the 95% confidence intervals (CIs). From 850 potentially relevant articles, twenty-five studies with a total of 18,067 eligible women were included in this study. The pooled national cervical cancer screening utilization was 14.79% (95% CI: 11.75, 17.83). The highest utilization of cervical cancer screening (18.59%) was observed in Southern Nations Nationalities and Peoples' region (SNNPR), and lowest was in Amhara region (13.62%). The sub-group analysis showed that the pooled cervical cancer screening was highest among HIV positive women (20.71%). This meta-analysis also showed that absence of women's formal education reduces cervical cancer screening utilization by 67% [POR = 0.33, 95% CI: 0.23, 0.46]. Women who had good knowledge towards cervical screening [POR = 3.01, 95%CI: 2.2.6, 4.00], perceived susceptibility to cervical cancer [POR = 4.9, 95% CI: 3.67, 6.54], severity to cervical cancer [POR = 6.57, 95% CI: 3.99, 10.8] and those with a history of sexually transmitted infections (STIs) [POR = 5.39, 95% CI: 1.41, 20.58] were more likely to utilize cervical cancer screening. Additionally, the major barriers of cervical cancer screening utilization were considering oneself as healthy (48.97%) and lack of information on cervical cancer screening (34.34%).

CONCLUSIONS

This meta-analysis found that the percentage of cervical cancer screening among eligible women was much lower than the WHO recommendations. Only one in every seven women utilized cervical cancer screening in Ethiopia. There were significant variations in the cervical cancer screening based on geographical regions and characteristics of women. Educational status, knowledge towards cervical cancer screening, perceived susceptibility and severity to cervical cancer and history of STIs significantly increased the uptake of screening practice. Therefore, women empowerment, improving knowledge towards cervical cancer screening, enhancing perceived susceptibility and severity to cancer and identifying previous history of women are essential strategies to improve cervical cancer screening practice.

Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting

INTRODUCTION

About 2.6 million stillbirths per year occur globally with 98% occurring in low- and middle-income countries including Kenya, where an estimated 35 000 stillbirths occur annually. Most studies have focused on the direct causes of stillbirth. The aim of this study was to determine the association between antenatal care utilization and quality with stillbirth in a Kenyan set up. This information is key when planning strategies to reduce the stillbirth burden.

MATERIAL AND METHODS

This was a case-control study in four urban tertiary hospitals carried out between August 2018 and April 2019. A total of 214 women with stillbirths (cases) and 428 with livebirths (controls) between 28 and 42 weeks were enrolled. Information was obtained through interviews and data abstracted from medical records. Antenatal care utilization was assessed by the proportions of women not attending antenatal care; booking first antenatal care visit in first trimester and not making the requisite four antenatal care visits. Quality of antenatal care was assessed using individual surrogate indicators (antenatal profile testing, weight/blood pressure/urinalysis testing in each antenatal visit, utilization of early obstetric ultrasound, completeness of antenatal records) and a codified indicator made up of seven parameters (attending antenatal care, booking first antenatal care in the first trimester, making four or more antenatal visits, having all antenatal profile tests, having a complete antenatal record, having blood pressure and weight measured at all visits). The association between antenatal care utilization and quality with stillbirth was assessed using univariate and multivariate analysis using logistic regression. Statistical significance was defined as a two-tailed P value ≤ .05.

RESULTS

Women with stillbirth were likely to have a parity ≥4 (19.6% vs 12.6%, P = .02), have an obstetric complication (36% vs 8.6%, P = .001) and have a medical disorder (5.6% vs 1.6%, P = .01). The odds of a stillbirth were four times higher among those who did not attend antenatal care ( odds ratio [OR] 4.1, 95% confidence interval [CI] 1.6-10, P < .003). Compared with four antenatal care visits, those who had one or two visits had higher odds of a stillbirth: OR 2.96 (95% CI 1.4-6.1), P = .003, and OR 2.9 (95% CI 1.7-5), P = .003, respectively. As per the individual surrogate indicators, the likelihood of a stillbirth was lower in women who received good quality antenatal care: Hemoglobin testing (OR 0.6, 95% CI 0.4-0.8, P = .03), blood group test (OR 0.4, 95% CI 0.2-0.6, P < .001), HIV test (OR 0.3, 95% CI 0.2-0.5, P = .001), venereal disease research laboratory test (OR 0.2, 95% CI 0.1-0.4, P = .001), weight measurement (OR 0.7, 95% CI 0.5-1.0, P = .047). As per the composite indicator, the quality of antenatal care was poor across the board and there was no association between this surrogate indicator and stillbirth.

CONCLUSIONS

Lack of antenatal care, attending fewer than four antenatal visits and poor quality antenatal care as measured by surrogate indicators were significantly associated with stillbirth. In addition, women with low education level, obstetric complications, multiparity and medical complications had a significantly higher likelihood of stillbirth. Improving the utilization of four or more antenatal visits and the quality of antenatal care can reduce the risk of stillbirth.

[Cancellations of Elective Surgeries on the Day of the Operation in a Portuguese Hospital: One Year Overview]

INTRODUCTION

Cancellations of elective operations on the day of the surgery reflect the efficiency and quality within organisations, and have a significant clinical, social and economic impact, not only for the patient and their families, but also for healthcare institutions. This study assesses the extent of these cancellations in one public Portuguese hospital, through case quantification and identification of the causes, origin, as well as its predictability according to the sociodemographic variables of the patient and interventions used to decrease it.

MATERIAL AND METHODS

Non-experimental descriptive quantitative methodology - longitudinal and retrospective - of operation cancellation cases on the day of the surgery, from the 1st of January to the 31st of December 2018.

RESULTS

The rate of cancellations of elective surgeries on the same day of the operation was 2.9% with variations among different surgical specialties; cancelled operations are more frequent in female patients, in patients aged between 50 and 80 years old, physical status classified as II or III according to the American Society of Anesthesiology, and without anaesthetic pre assessment or preoperative consultations; the three most relevant causes for cancellations are: lack of operative time, scarcity of beds and/or medical equipment, and changes in health status; most of which can be avoided and are the responsibility of the institution.

DISCUSSION

Different reasons for cancellation of elective operations reflect a variety of upstream and downstream processes causing cancellation of surgeries and whose origin/imputability is related to both the institution and patients.

CONCLUSION

The rate of cancellations of elective surgeries on the same day of the operation is relatively low, but the causes are often preventable, thus justifying the generalization of cancellation reduction strategies.

Insurance Coverage and Perinatal Health Care Use Among Low-Income Women in the US, 2015-2017

This cross-sectional study uses 2015-2017 data from the Pregnancy Risk Surveillance and Monitoring System to examine the association between health insurance coverage and use of perinatal health care among low-income women in the US.

Utilization fraction of rhinoplasty instrument sets: Model for efficient use of surgical instruments

OBJECTIVES

Recognize the avoidable costs incurred due to overpacking of rhinoplasty instrument trays. Reduce rhinoplasty instrument trays by including only instruments used frequently. Establish methods to reduce trays prepared for other otolaryngologic procedures.

METHODS

This is a prospective study. The study evaluates the specific use of instruments opened for rhinoplasty procedures at the New York Eye & Ear Infirmary of Mount Sinai. Instruments were counted in 10 rhinoplasty cases. Usage rate was calculated for each instrument. Additionally, all instruments used in at least 20% of cases were noted. This "20%" threshold was used to create new rhinoplasty tray inventories more reflective of actual instrument usage. Some instruments above the 20% threshold were included in multiples (i.e. two Adson Brown forceps vs. one curved iris scissor).

RESULTS

189 instruments were opened, and 32 instruments were used on average in each rhinoplasty. 55 instruments were used in at least 20% of cases. The 55 "high usage" instruments were used to create new, reduced rhinoplasty tray inventory lists. Based on our analysis, a new rhinoplasty tray inventory was created comprised of 68 instruments, a 64% reduction from 189.

CONCLUSION

Instruments are sterilized and packed in gross excess for rhinoplasty procedures. Previously published figures estimate re-sterilization costs of $0.51 to $0.77 per instrument. Reduction in instruments opened from 189 to 68 is expected to lead to cost savings ranging from $62 to $93 per case, yielding a savings between $6200 and $9300 per 100 cases performed.

LEVEL OF EVIDENCE

II-3.

International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records

There have been increasing calls for clinicians to document social determinants of health (SDOH) in electronic health records (EHRs). One potential source of SDOH in the EHRs is in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes (Z55-Z65). In February 2018, ICD-10-CM Official Guidelines for Coding and Reporting approved that all clinicians, not just the physicians, involved in the care of a patient can document SDOH using these Z codes.To examine the utilization rate of the ICD-10-CM Z codes using data from a large network of EHRs.We conducted a retrospective analysis of EHR data between 2015 to 2018 in the OneFlorida Clinical Research Consortium, 1 of the 13 Clinical Data Research Networks funded by Patient-Centered Outcomes Research Institute. We calculated the Z code utilization rate at both the encounter and patient levels.We found a low rate of utilization for these Z codes (270.61 per 100,000 at the encounter level and 2.03% at the patient level). We also found that the rate of utilization for these Z codes increased (from 255.62 to 292.79 per 100,000) since the official approval of Z code reporting from all clinicians by the American Hospital Association Coding Clinic and ICD-10-CM Official Guidelines for Coding and Reporting became effective in February 2018.The SDOH Z codes are rarely used by clinicians. Providing clear guidelines and incentives for documenting the Z codes can promote their use in EHRs. Improvements in the EHR systems are probably needed to better document SDOH.

Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data

BACKGROUND

Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs.

AIM

To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals.

METHOD

We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups.

RESULTS

One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively).

CONCLUSION

One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.

Health system utilization before age 1 among children later diagnosed with autism or ADHD

Children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) have 2-3 times increased healthcare utilization and annual costs once diagnosed, but little is known about their utilization patterns early in life. Quantifying their early health system utilization could uncover condition-specific health trajectories to facilitate earlier detection and intervention. Patients born 10/1/2006-10/1/2016 with ≥ 2 well-child visits within the Duke University Health System before age 1 were grouped as ASD, ADHD, ASD + ADHD, or No Diagnosis using retrospective billing codes. An additional comparison group was defined by later upper respiratory infection diagnosis. Adjusted odds ratios (AOR) for hospital admissions, procedures, emergency department (ED) visits, and outpatient clinic encounters before age 1 were compared between groups via logistic regression models. Length of hospital encounters were compared between groups via Mann-Whitney U test. In total, 29,929 patients met study criteria (ASD N = 343; ADHD N = 1175; ASD + ADHD N = 140). ASD was associated with increased procedures (AOR = 1.5, p < 0.001), including intubation and ventilation (AOR = 2.4, p < 0.001); and outpatient specialty care, including physical therapy (AOR = 3.5, p < 0.001) and ophthalmology (AOR = 3.1, p < 0.001). ADHD was associated with increased procedures (AOR = 1.41, p < 0.001), including blood transfusion (AOR = 4.7, p < 0.001); hospital admission (AOR = 1.60, p < 0.001); and ED visits (AOR = 1.58, p < 0.001). Median length of stay was increased after birth in ASD (+ 6.5 h, p < 0.001) and ADHD (+ 3.8 h, p < 0.001), and after non-birth admission in ADHD (+ 1.1 d, p < 0.001) and ASD + ADHD (+ 2.4 d, p = 0.003). Each condition was associated with increased health system utilization and distinctive patterns of utilization before age 1. Recognizing these patterns may contribute to earlier detection and intervention.

Utilization of integrated angiography-CT interventional radiology suites at a tertiary cancer center

BACKGROUND

Integrated Angiography-Computed Tomography (ACT) suites were initially designed in the 1990's to perform complex procedures requiring high-resolution cross-sectional imaging and fluoroscopy. Since then, there have been technology developments and changes in patient management. The purpose of this study was to review the current usage patterns of a single center's integrated ACT suites.

METHODS

All procedures performed in 2017 in 3 ACT suites (InterACT Discovery RT, GE Healthcare) at a tertiary cancer center were reviewed retrospectively. Usage was classified as: Standard, in which the patient underwent a single procedure using either fluoroscopy, CT, or ultrasound (US); Combined, in which the patient underwent a single procedure utilizing both fluoroscopy and CT; or Staged, in which the patient underwent 2 separate but successive procedures using fluoroscopy and CT individually. The most frequently performed Combined and Staged procedures were further reviewed to determine how the different modalities were used. The duration of the most common Staged procedures was compared to analogous procedures' durations in single modality rooms over the period Jan 2016 to Sep 2019.

RESULTS

A total of 3591 procedures were performed on 2678 patients in the 3 ACT Suites. 80% of patients underwent a Standard procedure using fluoroscopy (38%), CT (32%) or US (10%) and accounted for 70% of the room occupation time. Fourteen and three percent of the patients underwent Combined or Staged procedures, occupying 19 and 5% of the room time, respectively. The remaining procedures were classified as both Combined and Staged, representing 3% of the patients and 6% of the room occupation time. The most common Combined procedures were drainages, hepatic arterial embolizations or radioembolizations, arterial, and biliary interventions. The most common Staged procedures were multiple drainages and hepatic arterial embolizations followed by biopsies or ablations. The room occupation time for liver tumor embolization and ablation was significantly shorter (p < 0.01) when performed in a Staged fashion versus the analogous procedures in single modality room.

CONCLUSION

An integrated ACT system provides the capability to perform complex Combined or Staged procedures as well as scheduling flexibility by allowing any type of case to be performed in the IR suite.

Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis

OBJECTIVE

To investigate the association between the implementation of an integrated care (IC) system in Norrtälje municipality and changes in trends of the rate of emergency department (ED) visits.

DESIGN

Interrupted time series analysis from 2000 to 2015.

SETTING

Stockholm County.

PARTICIPANTS

All inhabitants 65+ years in Stockholm County on 31 December of each study year.

INTERVENTION

IC was established by combining the funding, administration and delivery of health and social care for older persons in Norrtälje municipality, within Stockholm County.

OUTCOME

Rates of hospital-based ED visits.

RESULTS

IC was associated with a decrease in the rate of ED visits (incidence rate ratio: 0.997, 95% CI 0.995 to 0.998) among inhabitants 65+ years in Norrtälje. However, the rate of ED visits remained higher in Norrtälje than the rest of Stockholm in the preintervention and postintervention periods. Stratified analyses showed that IC was associated with a decline in the trend of the rate of ED visits among those 65-79 years, the lowest income group and born outside of Sweden. However, there was no significant decrease in the trend among those 80+ years.

CONCLUSION

The implementation of IC was associated with a modest change in the trend of ED visits in Norrtälje, though the rate of ED visits remained higher than in the rest of Stockholm. Changes in the composition of the population and contextual changes may have impacted our findings. Further research, using other outcome measures is needed to assess the impact of IC on healthcare utilisation.

Trends in healthcare use in children aged less than 15 years: a population-based cohort study in England from 2007 to 2017

OBJECTIVE

To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017 DESIGN: Population-based retrospective cohort study.

METHODS

We used linked data from the Clinical Practice Research Datalink to study children's primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists.

RESULTS

Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (-1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017.

CONCLUSIONS

Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children's use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

Evaluation of Practice Patterns Among Oncologists Participating in the Oncology Care Model

Importance

Health insurers reimburse clinicians in many ways, including the ubiquitous fee-for-service model and the emergent shared-savings models. Evidence on the effects of these emergent models in oncological treatment remains limited.

Objectives

To analyze the early use and cost associations of a recent Medicare payment program, the Oncology Care Model (OCM), which included a shared savings-like component.

Design, Setting, and Participants

This nonrandomized controlled study used a difference-in-differences approach on 2 years of data, from July 1, 2015, to June 30, 2017-1 year before and 1 year after launch of the OCM-to compare the differences between participating and nonparticipating practices, controlling for patient, clinician, and practice factors. Participation in the OCM began on July 1, 2016. Associations of participation with care use and cost were estimated for care directly managed by clinicians from a large network within their Medicare populations for breast, lung, colon, and prostate cancers. Data were analyzed from September 2019 to March 2020.

Exposures

Participating practices were paid a monthly management fee of $160 per beneficiary and a potential risk-adjusted performance-based payment for eligible patients who received chemotherapy treatment, in addition to standard fee-for-service payments.

Main Outcomes and Measures

Office visits, drug administrations, patient hydrations, drug costs, and total costs.

Results

Monthly means data at the physician-level were evaluated for 11 869 physician-months for breast cancers, 11 135 physician-months for lung cancers, 8592 physician-months for colon cancers, and 9045 physician-months for prostate cancers. Patients at OCM practices had a mean (SD) age of 63.4 (3.1) years, and a mean (SD) of 59% (7 percentage points) of their patients were women. Participation in the OCM was associated with less physician-administered prostate cancer drug use (difference, 0.29 [95% CI, -0.47 to -0.11] percentage points, or 24.0%) translating to a mean of $706 (95% CI, -$1383 to -$29) less in drug costs per month. Monthly drug costs were also lower, at $558 (95% CI, -$1173 to $58) less for treatment for lung cancer. Total costs were lower by 9.7% or $233 (95% CI, -$495 to $30) for breast cancer, 9.9% or $337 (95% CI, -$618 to -$55) for lung cancer, 14.2% or $385 (95% CI, -$780 to $10) for colon cancer, and 29.2% or $610 (95% CI, -$1095 to -$125) for prostate cancer; however, these differences were largely offset by program costs. Clinician visits were also lower by 11.2% or 0.11 (95% CI, -0.20 to -0.01) percentage points among patients with breast cancer and by 14.4% or 0.19 (95% CI, -0.37 to -0.02) among patients with colon cancer.

Conclusions and Relevance

These findings suggest that payment models with shared-savings components can be associated with fewer visits and lower costs in certain cancer settings in the first year, but the savings can be modest given the costs of program administration.

Association of Health Care Use and Economic Outcomes After Injury in Cameroon

IMPORTANCE

Despite the highest injury rates worldwide, formal medical care is not often sought after injuries in Sub-Saharan Africa. Unaffordable costs associated with trauma care might inhibit injured patients from seeking care.

OBJECTIVES

To (1) determine the injury epidemiology in Cameroon using population-representative data, (2) identify the barriers to use of formal health care after injury, and (3) determine the association between use of care and economic outcomes after injury.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods, cross-sectional study included a population-representative, community-based survey and nested qualitative semistructured interviews in the urban-rural Southwest Region of Cameroon. Three-stage cluster sampling was used to select target households. Data were collected from January 3 to March 14, 2017, and analyzed from March 3, 2017, to March 3, 2019.

EXPOSURES

Injuries occurring in the preceding 12 months.

MAIN OUTCOMES AND MEASURES

Postinjury use of health care services, disability, and economic outcomes. All survey data were adjusted for cluster sampling.

RESULTS

Of 1551 total households approached, 1287 (83.0%) were surveyed for a total sample size of 8065 participants. The 8065 individuals surveyed included 4181 women (52.0%), with a mean age of 23.9 (standard error [SE], 0.2) years. A total of 503 injuries were identified among 471 unique participants, including 494 nonfatal injuries. Among these, 165 (34.6%) did not seek formal medical services. Disability occurred after 345 injuries (68.6%) and resulted in 11 941 lost days of work in the sample. Family economic hardship after injury was substantially increased among the injured cohort who used formal medical care. Injuries brought to formal medical care, compared with those that were note, incurred higher mean treatment costs ($101.08 [SE, $236.23] vs $12.13 [SE, $36.78]; P < .001), resulted in higher rates of lost employment (19.9% [SE, 3.6%] vs 5.6% [SE, 1.6%]; P = .004), and more frequently led affected families to use economic coping strategies, such as borrowing money (26.2% [SE, 2.7%] vs 7.1% [SE, 1.2%]; P < .001). After adjusting for age and severity, use of formal medical care in Cameroon was independently associated with severe economic hardship after injury, defined as a new inability to afford food or rent (adjusted odds ratio, 1.67; 95% CI, 1.05-2.65).

CONCLUSIONS AND RELEVANCE

In this study, injury in Southwestern Cameroon was associated with significant disability and lost productivity. Formal medical treatment of injury was associated with significant financial consequences for households of injured patients. Primary prevention of road traffic injuries and financial restructuring of emergency care could improve trauma care access in Cameroon and reduce the societal effects of injury.

Optimizing O-negative RBC utilization using a data-driven approach

BACKGROUND

O-negative red blood cells (ON-RBC) are a precious resource and the international blood banking community has become increasingly concerned with its inappropriate utilization. AABB recently made several recommendations to address the issue. Solutions must be multifaceted and involve donor centers, blood banks, and clinical departments. From the perspective of a hospital blood bank, it is difficult to rely solely on increased donor recruitment and ubiquitous blood typing of the entire in-patient population. We therefore focused on interventions within the blood bank to optimize inventory and policies to ensure appropriate ON-RBC utilization.

STUDY DESIGN AND METHODS

Transfusion data over one year was examined for the rate of out-of-group/inappropriate ON-RBC. Furthermore, we assessed whether that rate was related to product life on the day of transfusion. We also examined our stock inventory levels and how excess inventory can contribute to inappropriate ON-RBC usage.

RESULTS

The ON-RBC inventory level was decreased in order to reduce the rate of inappropriate transfusions while maintaining a safe level for optimal patient care. Compared to baseline, our intervention caused ON-RBCs to be transfused earlier in their shelf-life (9.27 vs. 11.15 days from expiration [DFE], p = 0.0012). This reduced the overall rate of inappropriate ON-RBC transfusions (67% vs. 54%, p = 0.0035), approximating 185 units of ON-RBC saved over the course of 6 months.

CONCLUSIONS

A data-driven approach to optimize stock inventory levels is widely applicable; it can be adopted by numerous institutions to improve utilization and establish a benchmark for the broader blood banking community.

ARTERIAL INSUFFICIENCIES: Hyperbaric Oxygen Therapy for Selected Problem Wounds

The use of hyperbaric oxygen (HBO2) for the treatment of selected problem wounds has focused almost entirely on the diabetic foot ulcer (DFU) in recent years. The prevalence of DFUs in today's patient population and the reimbursement available for the treatment of DFUs have given it priority status in discussions about problem wounds, but there are sound fundamental reasons why additional oxygen may have benefits in the treatment of non-DFU wounds.

Survey Results Regarding Uptake and Impact of Synthetic Digital Mammography With Tomosynthesis in the Screening Setting

Synthesized digital mammography (SM) was developed to replace digital mammography (DM) in digital breast tomosynthesis (DBT) imaging to reduce radiation dose. This survey assessed utilization and attitudes regarding SM in DBT screening. The study was institutional review board exempt. An online survey was sent to members of the Society of Breast Imaging in June 2018. Questions included practice information, utilization of DBT and SM, perception of change in recall rates (RRs) and cancer detection rates (CDRs) with SM-DBT versus DM-DBT, and attitudes regarding SM versus DM in DBT screening. χ2 Tests were used to compare response frequencies across groups. In all, 312 of 2,600 Society of Breast Imaging members responded to the survey (12%). Of respondents, 96% reported DBT capability, and 83% reported SM capability. Of those without SM, the most cited reasons were cost or administration and image quality concerns (both 32%). In addition, 40% reported combined SM and DM use in DBT screens, and 52% reported SM use without DM in the majority of DBT screens. The overall satisfaction with SM was 3.4 of 5 (1-5 scale). Most cited SM advantages were decreased dose (85%) and increased lesion conspicuity (27%). The most cited SM disadvantages were calcification characterization (61%) and decreased image quality (31%). Most respondents were unsure if CDRs changed (44%) and RR changed (30%) with few reporting adverse outcomes (6% RR increase, 1% CDR decrease). Most radiologists screening with DBT have SM, but only one-half have replaced DM with SM. Despite few reported adverse screening outcomes with SM-DBT, radiologists have concerns about image quality, specifically calcification characterization.

Supplemental Breast Imaging Utilization After Breast Density Legislation in North Carolina

PURPOSE

Breast density notification laws are increasingly common but little is known of how they affect supplemental screening use. The aim of this study was to investigate supplemental screening before and after density notification in North Carolina, where notification has been required since 2014.

METHODS

Breast screening data from Carolina Mammography Registry participants aged 40 to 79 years with no personal histories of breast cancer or breast implants were evaluated. Supplemental screening was defined as a nondiagnostic digital breast tomosynthesis (DBT), whole-breast ultrasound, or breast MRI performed within 3 months of negative or benign results on screening mammography (2-D or DBT). Supplemental screening before (2012-2013) and after (2014-2016) the notification law was compared using logistic regression.

RESULTS

During the study period, 78,967 women underwent 145,279 index screening mammographic examinations. Supplemental screening use was similar before and after the notification law, regardless of breast density (dense breasts: adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 0.58-1.75; nondense breasts: aOR, 0.63; 95% CI, 0.38-1.04). Although there was no change in supplemental screening, new use of any screening DBT from 2014 to 2016 was greater for women with dense breasts (versus nondense breasts; aOR, 1.15; 95% CI, 1.08-1.23).

CONCLUSIONS

Data suggest that supplemental screening use in North Carolina did not change after enactment of a breast density notification law, though the increase in new use of any screening DBT was greater for women with dense breasts. The short-term lack of change in supplemental screening should be considered as additional notification laws are developed.

Changes in Health Care Utilization for Pediatric Patients Treated at a Specialized Outpatient Pain Clinic

INTRODUCTION

Pediatric pain clinics may be the most efficacious way to manage chronic and recurrent pain in children and adolescents, but families often rely heavily on nonspecialized care, such as the emergency department (ED). Health care utilization patterns for pediatric chronic pain have not been fully explored, particularly the patient-level factors that may contribute to underutilization or overutilization of certain services.

OBJECTIVES

To identify health care utilization patterns before and after treatment at a pediatric pain clinic and the associations by primary diagnosis and patient sociodemographics.

METHODS

Data were obtained for all pediatric patients with an initial visit at an outpatient pediatric pain clinic between 2005 and 2009. Individual-level data included patient demographics, insurance type, and diagnosis at first pain clinic visit. Rate of health care system utilization 3 months before and after the initial pain clinic visit was quantified. Health care utilization rates before and after the initial visit to the pain clinic were compared using Wilcoxon signed-rank test.

RESULTS

Eight hundred twenty-six pediatric pain clinic patients were included. Overall, there were significant decreases in ED utilization (P < 0.001) and increases in outpatient service utilization (P < 0.001) after the initial pain clinic visit. Similar patterns were noted for patients by diagnosis (headache, musculoskeletal, or abdominal pain diagnoses) and among those who were female, white, 15 to 18 years old, privately insured, middle- or high-income (P < 0.05).

CONCLUSIONS

Visits to an outpatient pediatric pain clinic were associated with shifts in health care utilization patterns. Important changes were an overall decrease in emergency visits and an increase in outpatient visits.

Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact

OBJECTIVES

To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy.

DESIGN

This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale.

SETTING

Five NHS Hospital Trusts in the East Midlands region of England.

PARTICIPANTS

We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants.

INTERVENTIONS

Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope.

MAIN OUTCOME MEASURES

The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families.

RESULTS

Of the 339 respondents, 163 (48%) were aged <65 years, with 111 (68%) being in employment. Sixty-six (19%) participants had their operations cancelled on the day. Only 69 (62%) of working adults were able to return to work during the time scheduled for their operation, with a mean loss of 5 working days (SD 10). Additional working days were lost subsequently by 60 (54%) participants (mean 7 days (SD 10)). Family members of 111 (33%) participants required additional time off work (mean 5 days (SD 7)). Over 30% of participants reported extreme levels of sadness, disappointment, anger, frustration and stress. At least moderate concern about continued symptoms was reported by 234 (70%) participants, and 193 (59%) participants reported at least moderate concern about their deteriorating condition.

CONCLUSIONS

The cancellation of elective surgery during the winter had an adverse impact on patients and the economy, including days of work lost and health-related anxiety. We recommend better planning, and provision of more notice and better support to patients.

Utilization, effect, and benefit of the individualized Meeting Centers Support Program for people with dementia and caregivers

PURPOSE

There are few interventions on an individual basis to support community-dwelling people with dementia to continue to fulfill their potential in society and to support their informal caregivers via e-Health. This study explored the effectiveness of the individualized Meeting Centers Support Program (iMCSP) consisting of DemenTalent (people with dementia work as volunteers in a society based on their talents), Dementelcoach (telephone coaching), and STAR e-Learning for caregivers, compared to regular MCSP and No day care support.

METHOD

An explorative randomized controlled trial with pre/post measurements (M0-M6) and two groups (iMCSP and regular MCSP). In addition, a comparison was made between iMCSP and a reference No day care control group. Standardized questionnaires were administered on self-esteem, neuropsychiatric symptoms, experienced autonomy and quality of life of the person with dementia, and on caregiver's sense of competence, quality of life, and happiness.

RESULTS

The iMCSP interventions resulted in a broader group of participants utilizing the Meeting Centers. Compared to regular MCSP, DemenTalent had a moderate positive effect on neuropsychiatric symptoms, which also proved less severe. Positive affect of participants improved within the DemenTalent and regular MCSP group after six months. Caregivers of DemenTalent participants experienced less emotional impact of neuropsychiatric symptoms. No differences were found in experienced burden, sense of competence, or quality of life in caregivers using iMCSP or regular MCSP. Compared to those receiving No day care support, caregivers of DemenTalent participants and caregivers using Dementelcoach or STAR e-Learning proved happier. Post-hoc analyses, accounting for potential between-group differences in outcome measures at baseline, generally showed results in the same direction. People with dementia and caregivers highly appreciated iMCSP and regular MCSP.

CONCLUSION

iMCSP can be effectively applied as alternative or additional support via regular Meeting Centers for people with dementia and caregivers who prefer individualized activities/support. DemenTalent decreased the severity of neuropsychiatric symptoms of people with dementia and emotional burden of caregivers. All iMCSP interventions tended to result in caregivers being happier compared to those receiving no support. Larger-scale studies are needed to investigate the effect of iMCSP on other domains of quality of life of participants.

Utilization of Maternal Health Care Services among Mothers Residing at Slum Area

BACKGROUND

Appropriate utilization of maternal health care services is very important tool to reduce the maternal and child morbidity and mortality rate. This study was conducted to assess the utilization of maternal health care services by the women for their last pregnancy in one year period and to find out it's association with selected variables.

METHODS

Descriptive cross sectional study was conducted for one year by using semi-structured questionnaire among 285 mothers residing at slums area of Dharan sub-metropolitan city after taking written consent from them. Ethical clearance was obtained from Institutional Review Committee, BPKIHS and Dharan Sub-metropolitan city office. Simple random sampling followed by snowball sampling method was used to collect the data by interview method.

RESULTS

Majority (95.1%) had one Antenatal visit, 60.4% had initiated antenatal visit at first trimester and 78.99% had completed 4 or more antenatal visits. Only 35.8% had taken complete dose of iron and calcium. Majority 262 (91.92%) respondents have taken Tetanus Toxoid immunization and among them only 74.42% had taken 2 dose of TT injection. Women who delivered in health facility accounted for 70.9% but only 28.8% went for postnatal visit. Majority (65.3%) received health advice during postnatal period. Nearly 40% respondents used family planning after post partum period .There was significant association between utilization of antenatal and delivery services with Educational status of respondents and their husbands and number of pregnancy and between utilization of postnatal services with occupation of husband.

CONCLUSIONS

Utilization of maternal health care services, antenatal services utilization were satisfactory whereas postnatal services and family planning services utilization were very poor. Utilization of maternal health services should be encouraged by conducting public awareness programmes.

Multi-Morbid Health Profiles and Specialty Healthcare Service Use: A Moderating Role of Poverty

Increasing life expectancy in the USA makes a better understanding of the heterogeneous healthcare needs of the aging population imperative. Many aging studies have discovered multimorbid health problems focusing mainly on various physical health conditions, but not on combined mental or behavioral health problems. There is also a paucity of studies with older adults who use professional healthcare services caring for their mental and substance-related conditions. This study aims to enhance the knowledge of older peoples' complex healthcare needs involving physical, mental, and behavioral conditions; examine the relationship between multi-morbid health profiles and specialty healthcare service utilization; and investigate its association to poverty. The study data were derived from the National Survey on Drug Use and Health (NSDUH) in 2013 (n = 6296 respondents aged 50 years and older). To identify overall health conditions, nine indicators, including physical, mental, and substance/alcohol, were included. Healthcare service utilization was measured with four mutually exclusive categories: No treatment, mental health treatment only, substance use treatment only, and both. We identified four health profiles: Healthy (82%), having physical health problems (6%), physical and mental health problems (4%), and behavioral problems (8%). Older people's health profiles were differentially associated with healthcare use. Those living in poverty with both physical and mental health problems or substance/alcohol health problems were less likely to receive mental health and substance use treatments than those with more financial resources. Implications for geriatric healthcare practices and policy are discussed.

Changing Patterns in the Acute Pain Service: Epidural versus Patient-controlled Analgesia

This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998–2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.

Transthoracic Echocardiography: Impact on Diagnosis and Management in Tertiary Care Intensive Care Units

The purpose of this study was to evaluate the utility of transthoracic echocardiography (TTE) in an intensive care unit by determining its impact on diagnosis and management. Over a six-month time period, we performed a prospective observational study on all patients admitted to either the medical or the surgical intensive care unit. Structured interviews were conducted with referring physicians before and after the TTE to determine the referring physicians’ pre-TTE diagnosis, reasons for requesting the TTE, and whether the TTE resulted in a change in diagnosis and/or management. A total of 135 TTE examinations were done in 126 patients. The referring physicians deemed that clinical information was inadequate to make a definitive diagnosis and management plan in 36/135 (27%) of the requests. In 99/135 (73%) studies, physicians indicated that there was probably sufficient clinical information to formulate a diagnosis and management plan, but ordered a TTE to corroborate their clinical findings. Overall, a change in diagnosis occurred in 39/135 (29%) of studies, and a change in management in 55/135 (41%) of studies. Diagnosis was changed in 19/99 (19%) studies with adequate clinical data, and in 20/36 (56%) studies with inadequate clinical data (P<0.001). Management was changed in 34/99 (34%) of studies with adequate clinical data and in 21/36 (58%) of studies with inadequate clinical data (P=0.017). Of the 62 management changes, 57/62 (92%) changes were minor, and 5/62 (8%) were major. In conclusion we have found that TTE frequently resulted in a change in the diagnosis and management.

Costs and outcomes in evaluating management of unhealed surgical wounds in the community in clinical practice in the UK: a cohort study

OBJECTIVE

To evaluate the patient pathways and associated health outcomes, resource use and corresponding costs attributable to managing unhealed surgical wounds in clinical practice, from initial presentation in the community in the UK.

METHODS

This was a retrospective cohort analysis of the records of 707 patients in The Health Improvement Network (THIN) database whose wound failed to heal within 4 weeks of their surgery. Patients' characteristics, wound-related health outcomes and healthcare resource use were quantified, and the total National Health Service (NHS) cost of patient management was estimated at 2015/2016 prices.

RESULTS

Inconsistent terminology was used in describing the wounds. 83% of all wounds healed within 12 months from onset of community management, ranging from 86% to 74% of wounds arising from planned and emergency procedures, respectively. Mean time to healing was 4 months per patient. Patients were predominantly managed in the community by nurses and only around a half of all patients who still had a wound at 3 months were recorded as having had a follow-up visit with their surgeon. Up to 68% of all wounds may have been clinically infected at the time of presentation, and 23% of patients subsequently developed a putative wound infection a mean 4 months after initial presentation. Mean NHS cost of wound care over 12 months was £7300 per wound, ranging from £6000 to £13 700 per healed and unhealed wound, respectively. Additionally, the mean NHS cost of managing a wound without any evidence of infection was ~£2000 and the conflated cost of managing a wound with a putative infection ranged from £5000 to £11 200.

CONCLUSION

Surgeons are unlikely to be fully aware of the problems surrounding unhealed surgical wounds once patients are discharged into the community, due to inconsistent recording in patients' records coupled with the low rate of follow-up appointments. These findings offer the best evidence available with which to inform policy and budgetary decisions pertaining to managing unhealed surgical wounds in the community.

National Hospital Care Survey Demonstration Projects: Characteristics of Inpatient and Emergency Department Encounters Among Patients With Any Listed Diagnosis of Alzheimer Disease

Objective-This report demonstrates the use of National Hospital Care Survey (NHCS) data using Alzheimer disease (AD) as an outcome. Inpatient discharges and emergency room encounters among patients with AD are described to demonstrate the use of NHCS. The capability of NHCS to link across hospital settings and to the National Death Index (NDI) is highlighted. The data are unweighted and are not nationally representative. Methods-This study analyzed inpatient (IP) and emergency department (ED) data from the 83 nonchildren's hospitals in the 2014 NHCS, out of a sample of 581 hospitals that provided Uniform Bill (UB)-04 administrative claims data for both the IP and ED settings. Encounters with any listed diagnosis of AD were identified using an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Individual patients who had any encounter during calendar year 2014 were linked across different hospital-based settings during the same year and with NDI to identify deaths in 2014 or 2015. Results-Analyses are presented on IP and ED encounters with any listed diagnosis of AD to highlight the analytical capabilities of NHCS not available in previous surveys. New data elements not available in the National Hospital Discharge Survey (NHCS' predecessor survey) are analyzed, including intensive care use, and diagnostic and therapeutic services received. Linkage across hospital settings (IP and ED) allows for differentiation of patients who were admitted directly as inpatients from those who were admitted as inpatients from the ED, and allows for identification of patients with only an ED encounter. Linkage to NDI allows for analyses of the underlying cause of death for those deaths occurring in 2014 and 2015. Although these data are not nationally representative, NHCS provides unique analytical opportunities to examine health care utilization among patients with AD across settings.

Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review

BACKGROUND

Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention.

METHODS

A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings.

RESULTS

The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn.

CONCLUSIONS

The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO ( CRD42014015162 ).

Older Adults' Health Care Utilization a Year After Experiencing Fear or Distress from Hurricane Sandy

OBJECTIVE

To determine whether self-reports of disaster-related psychological distress predict older adults' health care utilization during the year after Hurricane Sandy, which hit New Jersey on October 29, 2012.

METHODS

Respondents were from the ORANJ BOWL Study, a random-digit dialed sample from New Jersey recruited from 2006 to 2008. Medicare hospital, emergency department (ED) and outpatient claims data from 2012 and 2013 were matched to 1607 people age 65 and older in 2012 who responded to follow-up surveys conducted from July 2013 to July 2015 to determine their hurricane-related experiences.

RESULTS

In total, 7% (107) of respondents reported they experienced a lot versus 93% (1493) respondents reported they experienced little or no fear and distress from Hurricane Sandy. Those who experienced a lot versus little or no fear and distress had higher probability of all-cause hospital admissions and more ED visits through 3 months (hazard ratio [HR]: 2.19, 95% CI: 1.03-4.63; incidence ratio [IR]: 2.57, 95% CI: 1.21-5.35), and ED and outpatient visits (IR: 2.20, 95% CI: 1.44-3.37; IR: 1.37, 95% CI: 1.02-1.87) through the year after the hurricane.

CONCLUSIONS

A self-reported assessment of disaster-related psychological distress is a strong predictor of older adults' health care needs the year after the disaster. The results indicate that disaster preparedness should extend beyond acute health care needs to address longer-term health consequences of disasters. (Disaster Med Public Health Preparedness. 2018;12:578-581).

Understanding total cost of care in advanced non-small cell lung cancer pre- and postapproval of immuno-oncology therapies

This study assesses resource utilization and total direct medical cost among patients in the United States starting systemic antineoplastic therapy (ST) pre- and postapproval of immuno-oncology (IO) agents for advanced non-small cell lung cancer. Adults diagnosed with lung cancer initiating first-line ST within 6 months of diagnosis during either the pre- (March 2013-March 2014) or post-IO (March 2015-December 2016) approval period were identified in a US-based multipayer administrative claims database. Excluded were patients with small cell lung cancer, secondary malignancies, less than 1 month follow-up, and those in clinical trials. Total cost (TC) was calculated from the date of initiation of treatment until the last follow-up. Propensity score matching was adjusted for differences in patient cohorts, including follow-up time. Binary multiple logistic regression assessed predictors of high TC (above mean) pre- and post IO. Mean TC per patient was higher pre-IO versus post IO in both unmatched ($165,548 vs $95,715) and matched analyses($129,977 vs $113,177). Hospitalization and emergency department (ED) visit rates were higher pre-IO versus postapproval. Predictors of high TC pre-IO included use of first-line combination therapy, radiation, targeted therapy, maintenance therapy, biomarker testing, more comorbidities, longer follow-up, first-line hospitalization, first-line cost above mean, and age 65 years and older. In the post-IO period, additional predictors of higher TC included use of IO, having mild liver disease or hemiplegia, and longer time to ST initiation. Early data show lower ED visit and hospitalization rates and associated lower TC in the post-IO era.

Use of Inpatient Palliative Care by Type of Malignancy

BACKGROUND

Although mounting evidence supports the use of palliative care (PC) to improve care experiences and quality of life for oncology patients, the frequency of and factors associated with PC use during oncology-related hospitalizations remain unknown.

MATERIALS AND METHODS

Using the National Inpatient Sample dataset, hospitalizations during 2012-2014 for a primary diagnosis of cancer with high risk of in-hospital mortality were identified. PC use was identified using the V66.7 ICD-9 code. Factors associated with the cost of hospitalization were identified using multivariable gamma regression.

RESULTS

During the study period, 124,186 hospitalizations were identified with a primary diagnosis of malignancy (melanoma, breast, colon, gynecologic, prostate, male genitourinary, head/neck, urinary tract, noncolon gastrointestinal, lung, brain, bone/soft tissue, endocrine, or nonlung thoracic). Most patients were treated at a teaching hospital (51-77% by cancer type), and use of PC ranged from 10% for patients with endocrine cancers to 31% for patients with melanoma. Patients utilizing PC had a lower frequency of operative procedures (4-33% vs. 34-79% by cancer type, all p ≤ 0.001), a higher rate of in-hospital death (30-45% vs. 4-10% by cancer type, all p < 0.001), and a lower total hospitalization cost (median: $5076-17,151 vs. $10,918-29,287 by cancer type, p ≤ 0.01 except male genitourinary). In an adjusted analysis, the cost of hospitalization was significantly associated (all p < 0.001) with patient gender, race, age, operative, in-hospital death, extended length of stay, and PC.

CONCLUSIONS

In summary, inpatient PC utilization varied by cancer type. PC was associated with lower utilization of surgical procedures, shorter length of stay, and lower hospitalization cost. Lower hospitalization cost was also seen for patients who were older, female, or African American.

Factors associated with appointment non-attendance at a medical imaging department in regional Australia: a retrospective cohort analysis

INTRODUCTION

Appointment non-attendance contributes added cost to the healthcare sector through wasted resource allocations. Medical imaging departments commonly schedule appointments for most modalities; however, no study has quantified patient attendance rates in the Australian regional setting. This is despite evidence that regional, rural and remote Australians tend to demonstrate poorer health than metropolitan counterparts. This study aims to identify the factors that influence appointment non-attendance at a teaching hospital in regional Australia.

METHODS

Categories restricted to age, gender, indigenous status, distance from investigation site, referral source and imaging modality were collected for all appointments (N = 13,458) referred to the medical imaging department in 2015. The likelihood of each of these factors correlating with a patient not attending a scheduled appointment was calculated using the chi-squared analysis and binary logistic regression.

RESULTS

Gender, indigenous status as well as specific imaging modalities, referral sources and age categories were significantly associated with non-attendance. Overall, male patients were 1.57 (P < 0.001) times more likely to miss a scheduled appointment than female patients. Patients who identified as Aboriginal and Torres Strait Islander were 2.66 (P < 0.001) times more likely to miss a scheduled appointment than patients who did not identify as Aboriginal and Torres Strait Islander.

CONCLUSIONS

Several key factors appear to affect medical imaging appointment non-attendance. Key factors include indigenous status, gender, image modality, referral source and age. Further improvement is required to better meet the needs of underrepresented patient demographics.

Prevalence of unjustified emergency department x-ray examination referrals performed in a regional Queensland hospital: A pilot study

INTRODUCTION

The underpinning principles of radiation protection are justification, optimisation and limitation. Each medical imaging referral that uses ionising radiation must balance the justification of exposure to radiation against the benefits of the examination. Scrutiny of justification is the role of radiographers, for general radiography, and is usually performed using the clinical details provided on the referral. International studies report up to 77% of medical imaging examinations are unjustified or inappropriate. In regional Queensland, justification seems to involve a subjective assessment and enforcement is ad hoc. This study aimed to determine the number of unjustified emergency department x-ray examinations performed in a regional Queensland hospital.

METHODS

An audit of the clinical details provided on x-ray referrals and in the medical records was performed on x-ray examinations undertaken within an 11-day period. Justification was determined by compliance with the Government of Western Australia's diagnostic imaging pathways.

RESULTS

Of the 186 referrals assessed, 75.3% were categorised as not having complied with the imaging pathway and were considered unjustified. When the clinical details in the patient's medical record were reviewed, in conjunction with the referral, the unjustified rate reduced to 49.2% of examinations.

CONCLUSION

Results demonstrate a lack of information transfer by referring clinicians and a lack of compliance with justification requirements for imaging by medical imaging staff. Improved communication regarding the need for imaging, and the refusal of referrals that are not justified, will ensure that patients are only exposed to radiation when clear benefit has been demonstrated.

Review of cardiovascular imaging in the Journal of Nuclear Cardiology in 2017. Part 2 of 2: Myocardial perfusion imaging

In 2017, the Journal of Nuclear Cardiology published many high-quality articles. In this review, we will summarize a selection of these articles to provide a concise review of the main advancements that have recently occurred in the field. In the first article of this 2-part series, we focused on publications dealing with positron emission tomography, computed tomography, and magnetic resonance. This review will place emphasis on myocardial perfusion imaging using single-photon emission computed tomography summarizing advances in the field including prognosis, safety and tolerability, the impact of imaging on management, and the use of novel imaging protocols.

Medicare Advantage enrollees' use of nursing homes: trends and nursing home characteristics

OBJECTIVES

To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients.

RESULTS

The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration.

CONCLUSIONS

MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building "networks" of postacute and long-term care providers that provide better and more efficient care.

Impact of presumed service-connected diagnosis on the Department of Veterans Affairs healthcare utilization patterns of Vietnam-Theater Veterans: A cross-sectional study

During the Vietnam War, the US military sprayed almost 20 million gallons of Agent Orange (AO), an herbicide contaminated with dioxin, over Vietnam. Approximately, 2.7 million US military personnel may have been exposed to AO during their deployment. Ordinarily, veterans who can demonstrate a nexus between a diagnosed condition and military service are eligible for Department of Veterans Affairs (VA) service-connected disability compensation. Vietnam Veterans have had difficulty, however, establishing a nexus between AO exposure and certain medical conditions that developed many years after the war. In response, VA has designated certain conditions as "presumed service connected" for Vietnam Veterans who were present and possibly exposed. Veterans with any of these designated conditions do not have to document AO exposure, making it easier for them to access the VA disability system. The extent to which VA healthcare utilization patterns reflect easier access afforded those with diagnosed presumptive conditions remains unknown. In this cross-sectional study, we hypothesized that Vietnam Veterans with diagnosed presumptive conditions would be heavier users of the VA healthcare system than those without these conditions. In our analysis of 85,699 Vietnam Veterans, we used binary and cumulative logit multivariable regression to assess associations between diagnosed presumptive conditions and VA healthcare utilization in 2013. We found that diagnosed presumptive conditions were associated with higher odds of 5+ VHA primary care visits (OR = 2.01, 95% CI: 1.93-2.07), 5+ specialty care visits (OR = 2.11, 95% CI: 2.04-2.18), emergency department use (OR = 1.22, 95% CI: 1.11-1.34), and hospitalization (OR = 1.23, 95% CI: 1.17-1.29). Consistent with legislative intent, presumptive policies appear to facilitate greater VA system utilization for Vietnam Veterans who may have been exposed to AO.

Implementation science theories to inform efforts for de-implementation of urologic oncology care practices resulting in overuse and misuse

The field of implementation science has been conventionally applied in the context of increasing the application of evidence-based practices into clinical care, given evidence of underusage of appropriate interventions in many settings. Increasingly, however, there is recognition of the potential for similar frameworks to inform efforts to reduce the application of ineffective or potentially harmful practices. In this article, we provide some examples of clinical scenarios in which the quality problem may be overuse and misuse, and review relevant theories and frameworks that may inform improvement activities.

Diabetes Care Management Teams Did Not Reduce Utilization When Compared With Traditional Care: A Randomized Cluster Trial

PURPOSE: Health services research evaluates redesign models for primary care. Care management is one alternative. Evaluation includes resource utilization as a criterion. Compare the impact of care-manager teams on resource utilization. The comparison includes entire panes of patients and the subset of patients with diabetes. DESIGN: Randomized, prospective, cohort study comparing change in utilization rates between groups, pre- and post-intervention. METHODOLOGY: Ten primary care physician panels in a safety-net setting. Ten physicians were randomized to either a care-management approach (Group 1) or a traditional approach (Group 2). Care managers focused on diabetes and the cardiovascular cluster of diseases. Analysis compared rates of hospitalization, 30-day readmission, emergency room visits, and urgent care visits. Analysis compared baseline rates to annual rates after a yearlong run-in for entire panels and the subset of patients with diabetes. RESULTS: Resource utilization showed no statistically significant change between baseline and Year 3 (P=.79). Emergency room visits and hospital readmission increased for both groups (P=.90), while hospital admissions and urgent care visits decreased (P=.73). Similarly, utilization was not significantly different for patients with diabetes (P=.69). CONCLUSIONS: A care-management team approach failed to improve resource utilization rates by entire panels and the subset of diabetic patients compared to traditional care. This reinforces the need for further evidentiary support for the care-management model's hypothesis in the safety net.

The quality of invasive breast cancer care for low reimbursement rate patients: A retrospective study

Though evidence-based treatments have been recommended for breast cancer, underuse of the treatments was still observed. To certain extent, patients' access to care, which can be enhanced by increasing the coverage of health insurance, could account for the current underuse in recommended care. This study aimed to examine the association between different proportions of reimbursement and quality of recommended breast cancer care, as well as length of hospital stay. In this retrospective study, 3669 patients diagnosed with invasive breast cancer between 1 June, 2011 and 30 June, 2013 were recruited. Seven quality indicators from preoperative diagnosis procedures to adjuvant therapy and one composite indicator were selected as dependent variables. Logistic regression and generalized linear models were used to explore the association between quality of care and length of hospital stay with different reimbursement rates. Compared with UEBMI (urban employment basic medical insurance), which represented high level reimbursement rate, patients with lower rates of reimbursement were less likely to receive core biopsy, HER-2 (human epidermal growth factor receptor-2) testing, BCS (breast conserving surgery), SLNB (sentinel lymph nodes biopsy), adjuvant therapy and hormonal treatment. No significant difference in preoperative length of hospital stay was observed among the three insurance schemes, however URBMI (urban resident basic medical insurance) insured patients stayed longer for total length of hospital stay. Significant disparities in utilization of evidence-based breast cancer care among patients with different proportions of reimbursement were observed. Patients with lower rate of reimbursement were less likely to receive recommended care. Our findings could provide important support for further healthcare reform and quality improvement in breast cancer care.

Aging in Activity Space: Results From Smartphone-Based GPS-Tracking of Urban Seniors

OBJECTIVES

Prior research emphasizes the importance of the residential neighborhood context during later life but little attention has been afforded to other areas that older adults encounter as they move beyond their residential environments for daily activities and social interactions. This study examines the predominance of the residential context within older adults' everyday lives.

METHOD

We provided 60 older adults in four New York City neighborhoods with iPhones, which captured Global Positioning Systems (GPS) locations at 5-min intervals over 1 week (n = 55,561) and 17 ecological momentary assessments (EMAs) over 4 days (n = 757) to assess real-time activities.

RESULTS

Older adults in our sample spent nearly 40% of their time outside of their residential tracts and they visited 28 other tracts, on average. Exercising, shopping, socializing, and social activities were especially likely to take place outside of residential tracts. Differences in residential and nonresidential poverty exposure vary across gender, race/ethnicity, education, car ownership, and residential areas.

DISCUSSION

Measuring activity space, rather than relying on residential tracts, allows examination of the social environments that are relevant for older adults' everyday lives. Variation in characteristics of activity spaces may be an underexplored source of differences in health and well-being during later life.

[Flight and migration : A challenge for medicine in Germany]

In 2015 about 1.1 million refugees came to Germany. As a consequence public health authorities as well as physicians in hospitals and surgeries were faced with considerable challenges and problems. Between January and March 2016 the German Society of Internal Medicine (DGIM) and the Professional Organisation of German Internists (BDI) initiated a survey among their members in order to ascertain which diseases and problems physicians were confronted with. A total of 28,063 members of the DGIM and BDI participated in the survey of which 3626 members answered all questions. This equals a response rate of 11.31 %. Of the respondents, 1865 (51.9 %) stated holding employment positions and 987 (27.4 %) were self-employed. The predominant number of physicians were under the impression that the composition of diseases needing treatment did not change within the time period under survey (55.7 % of employed and 73.7 % of self-employed physicians). Typical disease patterns of internal medicine were mentioned here. Most significant problems when treating migrants and refugees were linguistic communication, cultural affiliation, and psychological traumatic experiences. Little or nothing is known about the modalities of reimbursement for the respective health care areas, especially by physicians in employed positions (84.6 %). In agreement with the vote of the 119th Deutscher Ärztetag, DGIM and BDI recommend the introduction of a nationwide health insurance card for migrants and refugees.

Satisfaction with rehabilitative health care services among German and non-German nationals residing in Germany: a cross-sectional study

OBJECTIVES

Rehabilitation following medical conditions is largely offered as in-patient service in Germany. Foreign-national residents use rehabilitative services less often than Germans and attain less favourable treatment outcomes. These differences are independent of demographic, socioeconomic and health characteristics. Satisfaction with different aspects of rehabilitative care presumably affects the effectiveness of rehabilitative services. We compared the degree of satisfaction with different domains of the rehabilitative care process between Germans and non-German nationals residing in Germany.

METHODS

We used data from a cross-sectional rehabilitation patient survey annually conducted by the German Statutory Pension Insurance Scheme. The sample comprises 274 513 individuals undergoing medical rehabilitation in 642 hospitals during the years 2007-2011. Participants rated their satisfaction with different domains of rehabilitation on multi-item scales. We dichotomised each scale to low/moderate and high satisfaction. For each domain, a multilevel adjusted logistic regression analysis was conducted to examine differences in the levels of satisfaction between German and non-German nationals. Average marginal effects (AMEs) and 99.5% CI were computed as effect estimates. AMEs represent differences in the probability for the occurrence of the outcome.

RESULTS

Turkish nationals had a higher probability for being less satisfied with most aspects of their rehabilitation, with AMEs ranging between 0.05 (99.5% CI 0.00 to 0.09) for 'satisfaction with psychological care' and 0.11 (99.5% CI 0.08 to 0.14) for 'satisfaction with treatments during rehabilitation'. Patients from former Yugoslavia and from Portugal/Spain/Italy/Greece were as satisfied as Germans with most aspects of their rehabilitation.

CONCLUSIONS

Turkish nationals are less satisfied with their rehabilitative care than other population groups. This may be attributable to the diversity of the population in terms of its expectations towards rehabilitation. Rehabilitative care institutions need to provide services that are sensitive to the needs of all clients. Diversity management can contribute to this process.

Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals

OBJECTIVES

Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies.

METHODS

We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy.

RESULTS

Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28-2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%).

CONCLUSIONS

A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.

National patterns in imaging utilization for diagnosis of cardiac amyloidosis: A focus on Tc99m-pyrophosphate scintigraphy

BACKGROUND

Tc99m-pyrophosphate (Tc99m-PYP) scintigraphy has emerged as a diagnostic modality for transthyretin (TTR) cardiac amyloidosis (CA). We sought to examine the variability in test utilization across multiple centers in the US.

METHODS

An electronic, web-based survey addressing specifics on Tc-99m PYP imaging was emailed to ASNC members, totaling 2785 recipients. Only one response per institution was allowed.

RESULTS

Responses were collected from 101 centers between July 2 and July 27, 2015. Among the respondents, 24% performed Tc-99m PYP specifically for CA diagnosis. The most commonly used dose was 20 mCi (37%) and most centers (35%) imaged 1 hour after injection. Scans were most often interpreted by cardiologists (60%). Quantification of uptake was performed in 57% of institutions with almost half (43%) utilizing the heart-to-contralateral lung (H/CL) ratio.

CONCLUSIONS

This national survey shows relatively low penetrance and high variability in Tc99m-PYP scintigraphy for CA diagnosis highlighting the need for standardization.

[Not Available]

Zusammenfassung. Die SmW Stiftung für medizinischen Wissenstransfer wurde 2010 als private Kleinstiftung gegründet mit dem Ziel, in Ostafrika in grösseren und mittleren Spitälern (Referral Hospitals und District Hospitals) hochwertige Ultraschalldiagnostik einzuführen und ein modulares Kurssystem mit drei- bis viertägigen Kursen anzubieten.

Factors related to monitoring during admission of acute patients

Understanding the use of patient monitoring systems in emergency and acute facilities may help to identify reasons for failure to identify risk patients in these settings. Hence, we investigate factors related to the utilization of automated monitoring for patients admitted to an acute admission unit by introducing monitor load as the proportion between monitored time and length of stay. A cohort study of patients admitted and registered to patient monitors in the period from 10/10/2013 to 1/10/2014 at the acute admission unit of Odense University Hospital in Denmark. Admissions with at least one measurement were analyzed using quantile regression by looking at the impact of distance from nursing office, number of concurrent patients, wing type (medical/surgical), age, sex, comorbidities, and severity conditioned on how much patients were monitored during their admissions. We registered 11,848 admissions, of which we were able to link patient monitor readings to 3149 (26.6 %) with 50 % being monitored <1.4 % of total admission time. Distance from nursing office had little influence on patients monitored <10 % of their admission time. But for other patients, being positioned further away from the office reduced the level of monitoring. Higher levels of severity were related to higher degrees of monitoring, but being admitted to the surgical wing reduce how much patients were monitored, and periods with many concurrent patients lead to a small increase in monitoring. We found a significant variation concerning how much patients were monitored during admission to an acute admission unit. Our results point to potential patient safety improvements in clinical procedures, and advocate an awareness of how patient monitoring systems are utilized.

Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS)

BACKGROUND

Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC.

METHODS AND RESULTS

INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight "best practices" were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of 99mTc could be adjusted reflecting patient weight/habitus.

CONCLUSIONS

On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the "as low as reasonably achievable" (ALARA) principle.