Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions

Background

Efforts to improve patient safety have attempted to incorporate aviation industry safety standards. We sought to evaluate the cost and workforce implications of applying aviation duty-hour restrictions to the entire practicing physician workforce.

Methods

The work hours and personnel deficit for United States residents and practicing physicians that would be created by the adoption of aviation standards were calculated.

Results

Application of aviation standards to the resident workforce creates an estimated annual cost of $6.5 billion, requiring a 174% increase in the number of residents to meet the deficit. Its application to practicing physicians creates an additional annual cost of $80.4 billion, requiring a 71% increase in the physician workforce. Adding in the aviation industry's mandatory retirement age (65 years) increases annual costs by $10.5 billion. The cost per life-year saved would be $1,035,227.

Conclusions

Application of aviation duty-hour restrictions to the United States health care system would be prohibitively costly. Alternate approaches for improving patient safety are warranted.     

Neural activity involved in the perception of human and meaningful object motion

We characterized magnetoencephalographic responses during observation of point-light displays of human and object motion. Time courses of grand-mean source estimates were computed and time frequency maps were calculated. For both conditions, activity began in the posterior occipital and mid-parietal areas. Further, late peaks were observed in the parietal, sensory-motor and left temporal regions. Only observation of human motion resulted in activation of the right temporal area. Both viewing conditions resulted in alpha and beta event-related desynchronization over the parietal, sensory-motor and temporal areas. A significant increase in beta activity was seen in the posterior temporal region in the human motion condition. The visual analyses of human and object motion appear to involve both overlapping and divergent patterns of neural activity.     

Unintended consequences of regionalizing specialized VA addiction services

OBJECTIVE: From 1995 to 2000 the Department of Veterans Affairs (VA) dramatically reduced addiction treatment funding and regionalized specialized services to urban centers. By using New York State as an example, this study examined whether regionalization disproportionately affected rural versus urban veterans' use of VA and non-VA inpatient addiction services. METHODS: By using a comprehensive data set of VA and non-VA hospitalizations for 294,748 VA enrollees who were residents of New York State from 1998 to 2000, this study examined admission rates for addiction treatment to VA and non-VA centers to determine how rates differed between rural veterans and urban veterans. RESULTS: Between 1998 and 2000 rural veterans obtained 67% of their inpatient addiction care from the VA, compared with 54% for urban veterans (p<.001). Compared with 1998 levels, the odds ratios of admission to VA facilities for inpatient detoxification fell for both rural and urban veterans to .80 in 1999 and .65 in 2000 (both p<.05). Although odds ratios of non-VA inpatient admission for addiction treatment were stable over time for urban veterans, those for rural veterans fell from 1998 values, falling to .76 in 1999 (not significant) and .62 in 2000 (p<.001) for detoxification and to .66 in 1999 (not significant) and .51 in 2000 for rehabilitation (p<.05). Odds ratios for urban veterans' admission to VA facilities for rehabilitation fell to .51 in terms of 1998 rates in 1999 and .38 in 2000, but rural veterans' odds ratios fell more, to .31 and .16, respectively (p<.001 for all). CONCLUSIONS: In New York regionalization of VA addiction services disproportionately affected rural veterans. Rural veterans experienced concurrent reductions in VA and non-VA inpatient addiction services. The VA and other health care policy makers should consider the potential unintended consequences to rural populations of resource reallocation.     

Antipsychotic drugs up-regulate tryptophan hydroxylase in ADF neurons of Caenorhabditis elegans: role of calcium-calmodulin-dependent protein kinase II and transient receptor potential vanilloid channel

Antipsychotic drugs produce acute behavioral effects through antagonism of dopamine and serotonin receptors, and long-term adaptive responses that are not well understood. The goal of the study presented here was to use Caenorhabditis elegans to investigate the molecular mechanism or mechanisms that contribute to adaptive responses produced by antipsychotic drugs. First-generation antipsychotics, trifluoperazine and fluphenazine, and second-generation drugs, clozapine and olanzapine, increased the expression of tryptophan hydroxylase-1::green fluorescent protein (TPH-1::GFP) and serotonin in the ADF neurons of C. elegans. This response was absent or diminished in mutant strains lacking the transient receptor potential vanilloid channel (TRPV; osm-9) or calcium/calmodulin-dependent protein kinase II (CaMKII; unc-43). The role of calcium signaling was further implicated by the finding that a selective antagonist of calmodulin and a calcineurin inhibitor also enhanced TPH-1::GFP expression. The ADF neurons modulate foraging behavior (turns/reversals off food) through serotonin production. We found that short-term exposure to the antipsychotic drugs altered the frequency of turns/reversals off food. This response was mediated through dopamine and serotonin receptors and was abolished in serotonin-deficient mutants (tph-1) and strains lacking the SER-1 and MOD-1 serotonin receptors. Consistent with the increase in serotonin in the ADF neurons induced by the drugs, drug withdrawal after 24-hr treatment was accompanied by a rebound in the number of turns/reversals, which demonstrates behavioral adaptation in serotonergic systems. Characterization of the cellular, molecular, and behavioral adaptations to continuous exposure to antipsychotic drugs may provide insight into the long-term clinical effects of these medications.     

The Fear of Positive Evaluation Scale: assessing a proposed cognitive component of social anxiety

Cognitive-behavioral models propose that fear of negative evaluation is the core feature of social anxiety disorder. However, it may be that fear of evaluation in general is important in social anxiety, including fears of positive as well as negative evaluation. To test this hypothesis, we developed the Fear of Positive Evaluation Scale (FPES) and conducted analyses to examine the psychometric properties of the FPES, as well as test hypotheses regarding the construct of fear of positive evaluation (FPE). Responses from a large (n = 1711) undergraduate sample were utilized. The reliability, construct validity, and factorial validity of the FPES were examined; the distinction of FPE from fear of negative evaluation was evaluated utilizing confirmatory factor analysis; and the ability of FPE to predict social interaction anxiety above and beyond fear of negative evaluation was assessed. Results provide preliminary support for the psychometric properties of the FPES and the validity of the construct of FPE. The implications of FPE with respect to the study and treatment of social anxiety disorder are discussed.     

Where do veterans health administration patients obtain heart, liver, and kidney transplants?

We sought to determine whether Veterans Health Administration (VA) enrollees use the VA system or the private sector for solid-organ transplantation and whether VA system use is associated with patients' proximity to a VA transplant center. Using a national VA/Medicare inpatient data set and a comprehensive New York State VA/private-sector inpatient data set for 1998 to 2000, we found that veterans enrolled in the VA system obtained approximately one-half of their liver transplants, but few heart and kidney transplants, in the VA system. Patients were much more likely to use the VA system if they lived in a VA service area that offered relevant transplant services. Our findings suggest that VA transplant centers intended to meet national needs are more likely to serve local residents. Furthermore, our analysis indicates that use of only the VA/Medicare data set may substantially underestimate VA enrollees' reliance on the private sector for health care services.