Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Widening Participation To The Medical Course At Queens University Belfast

The United Kingdom Clinical Aptitude Test (UKCAT) was introduced to assist in identification of applicants from all levels of society with the appropriate characteristics to become good doctors. Evidence that the UKCAT has achieved such widened participation (WP) in applicants to medical school remains elusive. One of the limitations to WP investigation has been that data on socioeconomic status of applicants to medical schools has been obtained through voluntary submission on application to UKCAT and up to 30% of applications offered either none or only limited information. In this study of local applicants (451 from Northern Ireland) to Queens University Belfast (QUB) for 2012, socioeconomic data was ascertained through post code analysis. These data were utilized to investigate the relationship between affluence, application to the medical school and UKCAT score. Our study has shown that for NI applicants to QUB medical school, postcode /socioeconomic back ground accounts for only 3 percent of UK CAT score variation. We have also shown that our admissions process is largely independent of socioeconomic background. However we have demonstrated that the socioeconomic profile of applicants from Northern Ireland to QUB medical school is such that even if every applicant to QUB in 2012 were offered a place in the medical school the number of applicants from least affluent areas would increase by only 9. In conclusion efforts to achieve meaningful WP must be directed at raising aspirations for a career in Medicine within the community.

Short-time windows of correlation between large-scale functional brain networks predict vigilance intraindividually and interindividually

A better understanding of how behavioral performance emerges from interacting brain systems may come from analysis of functional networks using functional magnetic resonance imaging. Recent studies comparing such networks with human behavior have begun to identify these relationships, but few have used a time scale small enough to relate their findings to variation within a single individual's behavior. In the present experiment we examined the relationship between a psychomotor vigilance task and the interacting default mode and task positive networks. Two time-localized comparative metrics were calculated: difference between the two networks' signals at various time points around each instance of the stimulus (peristimulus times) and correlation within a 12.3-s window centered at each peristimulus time. Correlation between networks was also calculated within entire resting-state functional imaging runs from the same individuals. These metrics were compared with response speed on both an intraindividual and an interindividual basis. In most cases, a greater difference or more anticorrelation between networks was significantly related to faster performance. While interindividual analysis showed this result generally, using intraindividual analysis it was isolated to peristimulus times 4 to 8 s before the detected target. Within that peristimulus time span, the effect was stronger for individuals who tended to have faster response times. These results suggest that the relationship between functional networks and behavior can be better understood by using shorter time windows and also by considering both intraindividual and interindividual variability.

Nurse-led rapid access vascular examination clinic triage reduces inappropriate referrals for peripheral arterial disease

INTRODUCTION

Peripheral arterial disease causing intermittent claudication (IC) causes decreased quality of life and significant morbidity. We hypothesized that triage of patients referred with suspected IC at a nurse-led rapid access vascular examination (RAVE) clinic would identify those patients requiring vascular surgery assessment.

METHODS

A prospective cohort study was performed. Patients referred with suspected IC were assessed using the Edinburgh claudication questionnaire (ECQ) and arterial Doppler assessment with segmental waveform analysis and calculation of ankle brachial pressure index (ABPI). Data were collected regarding cardiovascular risk and its modification.

RESULTS

Of 451 consecutive patients, mean age was 65 years (range 30-89). Cardiovascular risk factors included: 173/451 (38%) current smokers (162/451 (36%) were ex-smokers); diabetes, 22%; hypertension, 46%; ischaemic heart disease (angina), 29%; dyslipidaemia, 27%. Therapeutic risk modifications included: antiplatelet therapy, 64.4%; lipid-lowering therapy, 57.8%. abnormal ABPI readings were present in 264/451 (59%), with ratio <0.9 in 209/451 (46.3%), >1.3 in 48/451 (10.6%), and incompressible vessels 7/451 (1.5%). Normal ABPI (ratio >0.9 and <1.3, triphasic Doppler waveforms) were found in 187/451 (41%), these patient were considered inappropriate referrals. Considering those patient with PAD diagnosed on abnormal ABPI (<0.9 or >1.3), Doppler waveform analysis was more sensitive and specific than ECQ.

CONCLUSIONS

Diagnosis of IC with clinical history alone is inaccurate in 41 percent of cases, leading to inappropriate referral to vascular surgery. Doppler waveform analysis had excellent sensitivity and specificity for prediction of ABPI <0.9. ABPI measurement in primary care could result in a more efficient use of clinical resources.

Triglyceride to HDL ratio is a reliable predictor of adverse outcomes in risk stratification for candidates undergoing abdominal aortic surgery

INTRODUCTION

The aim of this study was to establish if an elevated triglyceride to high-density lipoprotein (HDL) ratio (THR) is not only a risk factor for cardiovascular and overall morbidity as the updated evidence shows, but could also be employed as a significant predictor for surgical adverse outcomes and hence be a valid tool for risk stratification of candidates undergoing abdominal aortic surgery.

METHODS

This is a single-centre retrospective analysis of 2224 patients who underwent open abdominal aortic surgery between January 1996 and 2009. This cohort was divided into quartiles of THR. A list of covariates has been entered with THR into a multiple logistic model with forwards stepwise selection. The obtained result is an adjusted model, conceived to establish the association between THR and perioperative adverse events. Discrimination of the model so obtained and comparison with vascular-specific risk stratification scoring systems were evaluated using the area under the receiver operating characteristic (AUROC).

RESULTS

THR had the highest predictive value for the outcomes of interest. The adjusted odds ratios (ORs) per every 0.1 augmentation of THR were 1.41 (1.08-1.88) for cardiac, 1.38 (1.09-1.84) for respiratory, 1.27 (1.06-1.54) for renal adverse events and 1.02 (0.84-1.23) for mortality. Regarding mortality, either of the scoring systems Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and customised probability index (CPI) and the THR ranked as moderate discriminators, with THR performing the worst (AUROC 0.71) compared with Vascular POSSUM (AUROC 0.76) and CPI (AUROC 0.78). THR performed as a very strong predictor of morbidity (AUROC 0.86), ranking above Vascular POSSUM (AUROC 0.72).

CONCLUSIONS

THR is a significant predictor of perioperative morbidity and mortality. THR offers a broad outlook on the metabolic state of patients undergoing major abdominal aortic surgery and hence their propensity to adverse events, allowing us to risk-stratify the prognostic outcome of surgical intervention and possibly intervene preoperatively to optimise results.

In vitro activity of sorafenib against imatinib- and sunitinib-resistant kinase mutations associated with drug-resistant GI stromal tumors

10500

Background: Most gastrointestinal stromal tumors (GISTs) harbor mutant KIT or platelet-derived growth factor receptor alpha (PDGFRA) kinases, which are targets of imatinib (front-line therapy) or sunitinib (second-line therapy). Resistance to imatinib (IM) or sunitinib (SU) is commonly associated with the acquisition of secondary kinase mutations. In phase II studies, sorafenib (SOR), which targets KIT, PDGFRs, and several other kinases, has demonstrated efficacy in GIST patients after failure of IM and SU. We evaluated the in vitro activity of SOR against IM and/or SU resistant kinases. Methods: Kinase mutants were biochemically profiled for SOR, SU, and IM sensitivity by measuring inhibition of kinase phosphorylation after drug treatment in mutant-expressing CHO cells. We also tested the biochemical and cellular activity of SOR and IM against GIST cells derived from IM-resistant tumor clones. Results: SOR had superior potency to IM against IM-resistant KIT secondary mutations involving the ATP binding pocket (V654A, T670I) and the activation loop (D816H, D820A/G, N822K, Y823D). SOR and SU had similar potency against IM-resistant KIT secondary mutations involving the ATP binding pocket. In contrast, SOR had markedly increased potency, compared to SU, against IM-resistant KIT activation loop mutations. Both SOR and SU were more potent than IM against the isolated KIT exon 9 mutation. To confirm these observations in a GIST cellular context, we tested the relative potency of IM and SU against two previously described IM-resistant GIST cell lines (GIST430: exon 11 + V654A, GIST48: exon 11 + D820A). SOR was significantly more potent than IM against KIT in these cell lines. This also correlated with enhanced inhibition of downstream signaling pathways and cellular proliferation. Conclusions: SOR has superior in vitro potency compared with IM or SU against a panel of GIST-relevant mutant kinases. Notably, SOR, unlike SU, is active against most IM-resistant secondary mutations involving the KIT activation loop. Based on these results, we hypothesize that SOR might have superior clinical activity to SU in the setting of imatinib-resistant GIST and should be further evaluated for clinical efficacy in the second-line setting.

[Table: see text]

Clinical effectiveness and cost-effectiveness of laparoscopic surgery for colorectal cancer: systematic reviews and economic evaluation

OBJECTIVE

The aim of this study was to determine the clinical effectiveness and cost-effectiveness of laparoscopic, laparoscopically assisted (hereafter together described as laparoscopic surgery) and hand-assisted laparoscopic surgery (HALS) in comparison with open surgery for the treatment of colorectal cancer.

DATA SOURCES

Electronic databases were searched from 2000 to May 2005. A review of economic evaluations was undertaken by the National Institute for Health and Clinical Excellence in 2001. This review was updated from 2000 until July 2005.

REVIEW METHODS

Data from selected studies were extracted and assessed. Dichotomous outcome data from individual trials were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Summaries of the results from individual patient data (IPD) meta-analyses were also presented. An economic evaluation was also carried out using a Markov model incorporating the data from the systematic review. The results were first presented as a balance sheet for comparison of the surgical techniques. It was then used to estimate cost-effectiveness measured in terms of incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) for a time horizon up to 25 years.

RESULTS

Forty-six reports on 20 studies [19 randomised controlled trials (RCTs) and one IPD meta-analysis] were included in the review of clinical effectiveness. The RCTs were of generally moderate quality with the number of participants varying between 16 and 1082, with 10 having less than 100 participants. The total numbers of trial participants who underwent laparoscopic or open surgery were 2429 and 2139, respectively. A systematic review of four papers suggested that laparoscopic surgery is more costly than open surgery. However, the data they provided on effectiveness was poorer than the evidence from the review of effectiveness. The estimates from the systematic review of clinical effectiveness were incorporated into a Markov model used to estimate cost-effectiveness for a time horizon of up to 25 years. In terms of incremental cost per life-year, laparoscopic surgery was found to be more costly and no more effective than open surgery. With respect to incremental cost per QALY, few data were available to differentiate between laparoscopic and open surgery. The results of the base-case analysis indicate that there is an approximately 40% chance that laparoscopic surgery is the more cost-effective intervention at a threshold willingness to pay for a QALY of pound 30,000. A second analysis assuming equal mortality and disease-free survival found that there was an approximately 50% likelihood at a similar threshold value. Broadly similar results were found in the sensitivity analyses. A threshold analysis was performed to investigate the magnitude of QALY gain associated with quicker recovery following laparoscopic surgery required to provide an incremental cost per QALY of pound 30,000. The implied number of additional QALYs required would be 0.009-0.010 compared with open surgery.

CONCLUSIONS

Laparoscopic resection is associated with a quicker recovery (shorter time to return to usual activities and length of hospitalisation) and no evidence of a difference in mortality or disease-free survival up to 3 years following surgery. However, operation times are longer and a significant number of procedures initiated laparoscopically may need to be converted to open surgery. The rate of conversion may be dependent on experience in terms of both patient selection and performing the technique. Laparoscopic resection appears more costly to the health service than open resection, with an estimated extra total cost of between pound 250 and pound 300 per patient. In terms of relative cost-effectiveness, laparoscopic resection is associated with a modest additional cost, short-term benefits associated with more rapid recovery and similar long-term outcomes in terms of survival and cure rates up to 3 years. Assuming equivalence of long-term outcomes, a judgement is required as to whether the benefits associated with earlier recovery are worth this extra cost. The long-term follow-up of the RCT cohorts would be very useful further research and ideally these data should be incorporated into a wider IPD meta-analysis. Data on the long-term complications of surgery such as incisional hernias and differences in outcomes such as persisting pain would also be valuable. Once available, further data on both costs and utilities should be included in an updated model. At this point, further consideration should then be given as to whether additional data should be collected within ongoing trials. Few data were available to assess the relative merits of HALS. Ideally, there should be more data from methodologically sound RCTs. Further research is needed on whether the balance of advantages and disadvantages of laparoscopic surgery varies within subgroups based on the different stages and locations of disease. Research relating to the effect of experience on performance is also required.

Positive fluid balance is associated with complications after elective open infrarenal abdominal aortic aneurysm repair

BACKGROUND

Open abdominal aortic aneurysm (AAA) repair is associated with cardiac and respiratory complications and an overall mortality rate of 2 to 8%. We hypothesised that excessive fluid administration during the perioperative period contributes to complications and poor outcome after AAA repair.

METHODS

This was a retrospective cohort study. Medical records were analysed for fluid balance and complications in 100 consecutive patients treated by open AAA repair at a single centre between 2002-2005. Mortality and all major adverse events (MAE) such as myocardial infarction (MI), cardiac arrhythmia (Arr), pulmonary oedema (PO), pulmonary infection (PI), and acute renal failure (ARF) were included in the analysis. Level of care and hospital stay, were also recorded.

RESULTS

There were no in-hospital deaths. MAE occurred in 40/100 (40%): MI (6%); Arr (14%); PO (14%); PI (25%); ARF (8%). Complications were not predicted by preoperative cardiovascular risk factors, operative and clamp time, or blood loss. Patients with complications had significantly greater cumulative positive fluid balance on postoperative day 0 (p<0.01), day 1 (p<0.05), day 2 (p<0.03) and day 3 (p<0.04). This relationship also existed for individual complications such as MI, and pulmonary oedema. These patients had significantly longer ICU/HDU (p<0.002) and hospital stay (p<0.0001).

CONCLUSIONS

Serious complications are common after elective open AAA repair, and we have shown that positive fluid balance is predictive of major adverse events increased HDU/ICU and overall hospital stay.

Positive fluid balance is associated with complications after elective open infrarenal abdominal aortic aneurysm repair

BACKGROUND

Open abdominal aortic aneurysm (AAA) repair is associated with cardiac and respiratory complications and an overall mortality rate of 2 to 8%. We hypothesised that excessive fluid administration during the perioperative period contributes to complications and poor outcome after AAA repair.

METHODS

This was a retrospective cohort study. Medical records were analysed for fluid balance and complications in 100 consecutive patients treated by open AAA repair at a single centre between 2002-2005. Mortality and all major adverse events (MAE) such as myocardial infarction (MI), cardiac arrhythmia (Arr), pulmonary oedema (PO), pulmonary infection (PI), and acute renal failure (ARF) were included in the analysis. Level of care and hospital stay, were also recorded.

RESULTS

There were no in-hospital deaths. MAE occurred in 40/100 (40%): MI (6%); Arr (14%); PO (14%); PI (25%); ARF (8%). Complications were not predicted by preoperative cardiovascular risk factors, operative and clamp time, or blood loss. Patients with complications had significantly greater cumulative positive fluid balance on postoperative day 0 (p<0.01), day 1 (p<0.05), day 2 (p<0.03) and day 3 (p<0.04). This relationship also existed for individual complications such as MI, and pulmonary oedema. These patients had significantly longer ICU/HDU (p<0.002) and hospital stay (p<0.0001).

CONCLUSIONS

Serious complications are common after elective open AAA repair, and we have shown that positive fluid balance is predictive of major adverse events increased HDU/ICU and overall hospital stay.

Pilot study of sexual dysfunction following abdominal aortic aneurysm surgery

INTRODUCTION

The complication of sexual dysfunction as a quality of life (QoL) component after abdominal aortic aneurysm (AAA) surgery in men is poorly studied.

AIMS

To investigate the prevalence of sexual dysfunction and to highlight the importance of discussing this issue with patients undergoing AAA repair.

MAIN OUTCOME MEASURES

The self-reported sexual dysfunction prevalence pre- and postoperatively, the effects on sexual QoL, and the postoperative Sexual Health Inventory for Men (SHIM) scores.

METHODS

Between April 1999 and July 2002, a questionnaire-based study, including the SHIM, was conducted on male patients 1-2 years after their elective open (EO) and rupture open (RO) or endovascular repair (EVAR) AAA repair. Demographics, risk factors for sexual dysfunction, sexual history, and postoperative sexual QoL data were obtained.

RESULTS

Out of 142 alive male patients surveyed, 56 (40%) patients responded (26 EO, 21 EVAR, and 9 RO repair). The mean age was 69, 73, and 70 years, respectively, and 65%, 66%, and 66%, respectively, admitted to be sexually active postoperatively. The self-reported sexual dysfunction prevalence preoperatively was 27% (EO), 63% (EVAR), and 45% (RO); and postoperatively was 58%, 76%, and 67%, respectively. Detection using SHIM was higher at 70%, 95%, and 78%, respectively. There was a significantly greater increase in the postoperative prevalence of sexual dysfunction in the EO group than in the EVAR group (P < 0.05, chi(2)). The sexual QoL was worsened postoperatively in all groups: 53% (EO), 75% (EVAR), and 50% (RO); but only one-third of EO and EVAR patients, and none in RO patients, would seek treatment for their sexual dysfunction.

CONCLUSION

There was a negative impact on the sexual QoL in all groups after surgery, and a significantly higher proportion of patients experienced deterioration in sexual QoL following EO surgical repair. Our results demonstrate the need for a prospective study.

Health care providers and facilities: medical malpractice and tort reform--2005. End of Year Issue Brief

As health care professionals continue to feel the crunch of rising malpractice insurance rates and increased jury awards, medical malpractice remains a priority for acute care professionals. Medical associations claim that rapidly increasing premiums and the declining number of insurers often lead physicians to stop practicing medicine or to relocate. This may lead to a shortage of physicians, particularly physicians who practice high-risk specialties such as neurology. The pressure to retain an adequate supply of health care professionals is particularly acute in rural areas. It is difficult to pinpoint the origins of the escalating cost of medical malpractice coverage. Insurers and physicians claim excessive litigation and overly generous jury awards have hardened the market. Trial lawyers and consumer advocacy groups assert insurance premium rates have not reflected increasing medical inflation or the payouts of jury awards during the last 30 years. The majority of states have some form of basic coverage requirement that medical malpractice insurers must offer. However, because of the complexities and variety of coverage plans, physicians often are unaware that gaps in coverage exist. As of May 2005, the American Medical Association (AMA) has declared a state

Health care providers and facilities: health facilities--2005. End of Year Issue Brief

The mission of every hospital in America is to serve the health care needs of individuals in their communities, 24 hours a day, seven days a week. Their task, and the task of their medical staff, is to continually care for and to cure their patients. American health facilities are said to provide the best, most sophisticated, and most beneficial health care in the world. However, a hospital's ability to care for each patient who walks through their doors is continuously challenged on numerous fronts--the shortage of key hospital personnel, the increased cost of caring for the uninsured, the continued problem of medical errors, and the growth of niche and specialty hospitals. As of 2002, there were 5,794 registered hospitals in the United States, according to the most recent data available from the American Hospital Association (AHA). The AHA also states that there are 4,927 community hospitals, which includes nongovernmental, non-profit hospitals, investor-owned (for-profit) hospitals, and hospitals owned by state and local governments. The AHA defines community hospitals as all non-federal, short-term general and other specialty hospitals. Specialty hospitals include obstetrics and gynecology, rehabilitation, orthopedic and other individually described specialty services. Statistics provided by the AHA indicate that the number of rural and urban community hospitals is approximately equal--2,178 rural hospitals compared to 2,749 urban hospitals.

Public health: tobacco taxes and Internet sales--2005. End of Year Issue Brief

Raising tobacco taxes is an action that resonates with lawmakers, public health and anti-tobacco advocates, and the majority of the electorate. The relatively broad base of support for increasing excise taxes and the potential for increased tax revenue mitigate the concerns over targeting tobacco-users--23 percent of the population--to pay for state programs and the unreliability of the tobacco tax as a permanent source of revenue. Tobacco excise taxes generated $10.2 billion, or about 1.5 percent of all states' revenue. Characterized as sin taxes or user fees and viewed as an effective method to deter price-sensitive adolescents from using tobacco, excise taxes on tobacco have increased in an unprecedented number of states since November 2001. Previously, no more than three states, on average, had increased cigarette taxes in a year. The legislative action is viewed as a politically safe and relatively easy way to raise taxes and increase revenue without incurring the wrath of anti-tax voters. During this period the increases in tobacco taxes ranged from a $0.12 per pack increase in Louisiana to a $0.75 increase in Massachusetts and Michigan. Nationwide the state tax rate per pack of cigarettes ranges from a low in South Carolina of $0.07 to $2.46 in Rhode Island. The mean tobacco excise tax for the nation is approximately $0.92. With an excise tax increase, states can channel needed funds to programs favored by voters in economically strapped times. Indeed, many of the 44 states that increased their tobacco tax announced that the revenue would permit the state to restore or at least reduce proposed cuts to Medicaid and other health programs. Excise taxes also place little administrative burden on states, since the wholesaler pays the tax directly to the state and the additional cost then is passed on to the consumer.

Health care providers and facilities issue brief: health facilities: year end report-2004

American health facilities are said to provide the best health care in the world. But hospitals are continually challenged by staff shortages, patient safety and medical errors, uninsured patients, and the growth of specialty hospitals. This issue brief provides an analysis of the issues that challenge hospitals' ability to provide quality care for patients. Moreover, the issue brief defines each issue, including staffing mandates, patient safety and medical errors, emergency hospitals, billing practices, and niche and specialty hospitals, outlines the arguments for and against each issue, and finally details and characterizes state legislative activity in regard to each issue. As of 2002, the most recent data available from the American Hospital Association (AHA), there were 5,794 registered hospitals in the United States. The AHA also states that there are 4,927 community hospitals, which includes non-governmental non-profit hospitals, investor-owned (for-profit) hospitals, and hospitals owned by state and local governments. The AHA defines community hospitals as all non-federal, short-term general, and other specialty hospitals. Specialty hospitals include obstetrics and gynecology, rehabilitation, orthopedic, and other individually described specialty services. Statistics provided by the AHA indicate that the number of rural and urban community hospitals is approximately equal--2,178 rural hospitals compared to 2,749 urban hospitals. However, this statistic alone does not address the quality of care in urban and rural settings. It does not address the total expenditures in rural and urban hospitals, nor does it address staffing levels.

Health care providers and facilities issue brief: nursing shortages: year end report-2004

Many states across the nation are seeking ways to retain registered nurses and curb rising workforce shortages. Some state governments have established scholarship and loan forgiveness programs to increase the number of people pursuing a career in nursing. State lawmakers are also providing incentives to increase the number of nurse educators. Hospitals are offering childcare subsidies and employers are offering flexible hours and signing bonuses. The Journal of the American Medical Association (JAMA) released a study in June 2000 estimating a 20 percent shortage of registered nurses by 2020 in the United States. A nursing shortage exists in this country for several reasons. First, according to the American Association of Colleges of Nursing, enrollment in bachelor's programs has declined steadily for the last five years. Moreover, the nursing work force is aging; less than 10 percent of registered nurses are under the age of 30. The numbers are expected to further decline because many baby boomers will be retiring by 2010. Lastly, nurses' salaries, on average, are inadequate compared to other professions.

Health care providers and facilities issue brief: certificate of need: year end report-2004

At one time, every state was required by the federal government to have a certificate of need (CON) program. The process was intended to keep down costs associated with the construction of new health facilities in the state, and prevent over development. When the federal requirement was lifted, however, a number of states did away with their programs. Some later restored them in some form, and many have kept their programs alive for years, requiring a governmental seal of approval for building new facilities such as hospitals and long-term care facilities or for acquiring major medical equipment.

Providers issue brief: tobacco: excise taxes: year end report-2003

All 50 states, the District of Columbia, and the federal government impose excise taxes on cigarettes and have done so for many years. State tobacco taxes range from a high of $2.05 per pack of cigarettes in New Jersey to a low of $0.03 in Virginia per pack. The federal government levies an excise tax that increased by $0.05 on Jan. 1, 2002, to $0.39 per package. Cigarette taxes are directed at the consumer, while taxes on other tobacco products focus on the wholesaler. In the 2002 legislative sessions, 33 states proposed increases in cigarette excise taxes as a means of addressing budget shortfalls; 20 states enacted increases. Increasing tobacco excise taxes may decrease tobacco usage and increase state revenue. Increasing cigarette taxes is a means of generating revenue that generally is supported by public opinion. For instance, a 2003 poll in Ohio found that 63 percent of the public favored increasing cigarette excise taxes as long as the revenue is used for health care purposes. Cigarette excise taxes was again an area of substantial legislative interest and activity due to continued state budget deficits. A February 2003 NCSL study of state budget shortfalls indicated that the current cumulative budget gap is approximately $25.7 billion for fiscal year (FY) 2003. State revenues were sluggish and generally most failed to meet budgeted levels. At least 30 states noted that general fund collections were below budgeted estimates, and 12 states reported that collections failed to meet revised levels. Although the additional tax revenue generated by raising excise taxes may not eliminate state budget shortfalls, the revenue may provide funds for specific state programs.This issue brief provides an overview of the policy issue, a brief history of tobacco taxation in the 50 states and the District of Columbia, an overview of legislative activity in 2003, and a state-by-state map of state tobacco taxes.

Providers issue brief: tobacco: youth access to tobacco: year end report-2003

The use of tobacco products by adolescents concerns advocacy organizations, state departments of public health, state legislatures and tobacco manufacturers. Research conducted by the Centers for Disease Control and Prevention concludes that more than half of all smokers begin smoking before the age of 14, and 90 percent begin by age 19. The average age of first use is between age 13 and age 14. The earlier adolescents use tobacco, the more likely they are to use it as adults and the longer potential time they have to become habitual users. Both the duration and the amount of tobacco use are related to eventual chronic health problems, and these chronic health problems add to the states' medical costs. For instance, the treatment of tobacco-related illnesses collectively cost the states $50 billion to $75 billion annually

Behavioral health issue brief: mental health and children: year end report-2003

Children with mental health problems face many treatment barriers. Health care coverage, cost, access and availability of services are just a few. Parents are often faced with difficult decisions about their child's treatment. Sometimes the task of finding and paying for treatment is too great and the burden falls on state and county systems of care. Beyond the question of how to obtain services is the question of how to provide them. Since 1999, the debates over the use of physical restraints and psychotropic medications has become more heated.

Behavioral health issue brief: state budget actions that affect public mental health services and systems: year end report-2003

With ongoing declines in the economy, states have readjusted their FY 2003 budgets throughout the fiscal year, while at the same time negotiating their upcoming FY 2004 and FY 2005 budgets. Because of the current fluidity of state budgets, this issue brief contains snapshots of actions taken at various times throughout FY 2003. It is intended to provide the reader with a general overview of the effects on public mental health systems, of the decline in state economies. The Health Policy Tracking Service (HPTS) will continue to track this issue, and will update this brief at quarterly intervals.

Behavioral health issue brief: parity and other insurance mandates for the treatment of mental illness and substance abuse: year end report-2003

Parity and other insurance mandates for the treatment of mental illness and substance abuse continue to be on the agenda of many state legislatures. A broad spectrum of opinions surround what mandates for mental health and substance abuse could and should be. The debate over mandated benefit legislation typically centers around consumer protection versus cost. There are strong opponents, for example, that advocate for nothing less than full parity for mental health and substance abuse treatment. Equally strong are the groups that oppose parity because they believe it will lead to a health care cost increase and, therefore, an increase in the number of uninsured. Both sides continue to make progress as the victories and the defeats unfold on the floors of state legislatures.

Use of clinical audit for revalidation: is it sufficiently accurate?

In order to provide better patient care, clinicians will be subject to revalidation and re-certification. This may be partially based on existing and ongoing data collection, yet many units fail to incorporate mechanisms that validate the data that may be used. The accuracy of audit data was evaluated in a unit that has been using commercially available audit software for over 10 years. A total of 655 consecutive surgical admissions were documented over a 6-month period and errors in data collection and entry were gathered and analyzed. An overall accuracy of 90.5% was confirmed but examination of the data found them to be open to misinterpretation. Moreover, 13% of errors were made during a single week when locum staff were involved. The study highlights the fallibility of data collection during audit, and urges caution if using such data when judging performance-related issues as part of the process of appraisal.