Matching Capacity to Demand: A Regional Dashboard Reduces Ambulance Avoidance and Improves Accessibility of Receiving Hospitals

Objectives: Ambulance diversion is a dangerous repercussion of emergency department (ED) crowding and can reflect fragmentation and a lack of coordination in designating optimal patient offload sites for prehospital providers. The objective of this study was to evaluate whether proactive destination selection through the Regional Emergency Patient Access and Coordination (REPAC) program would enhance capacity and ED flow management. Methods: The REPAC system provides a dashboard that synthesizes real‐time capacity and acuity data for all three adult EDs in the city of Calgary, assigning a color code to reflect receiving status. It assigns destination for the next patient transported by emergency medical services (EMS) by categorizing ED sites as having either a favorable (green/yellow) status or unfavorable (orange/red) status. Three time windows were analyzed: a 6‐month window prior to REPAC implementation (pre), the first 6‐month window immediately following (post1), and the second 6‐month period following (post2). Primary outcomes of interest were the proportion of time spent in favorable versus unfavorable status and EMS avoidances for all adult ED sites in the region (percentage of total time with any center on EMS bypass). Information on total number of ED visits, percentage of patients arriving by EMS transports, admission rates, patient acuity (Canadian Triage and Acuity Score), age, and length of stay (LOS) for admitted and discharged patients was collected. The Kruskal‐Wallis test was employed for primary outcome analysis. Results: Implementation of the REPAC system resulted in an increase in the proportion of total time region hospitals reported favorable status (57.5% vs. 64.1%) pre versus post1, an effect that was accentuated at 1 year (post2, 78.7%; p < 0.001 for both comparisons). There was a concomitant decrease in EMS avoidances as a result of the REPAC system, 4.4% to 1.8% (pre vs. post1), also further improved at 1 year to 0.6% (p < 0.001 for both comparisons). Conclusions: Proactive EMS destination selection through a real‐time integrated electronic surveillance system enhances regional capacity and flow management while significantly reducing ambulance diversions. ACADEMIC EMERGENCY MEDICINE 2010; 17:1383–1389 © 2010 by the Society for Academic Emergency Medicine     

Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making: An ISPOR-AMCP-NPC Good Practice Task Force Report

The evaluation of the cost and health implications of agreeing to cover a new health technology is best accomplished using a model that mathematically combines inputs from various sources, together with assumptions about how these fit together and what might happen in reality. This need to make assumptions, the complexity of the resulting framework, the technical knowledge required, as well as funding by interested parties have led many decision makers to distrust the results of models. To assist stakeholders reviewing a model’s report, questions pertaining to the credibility of a model were developed. Because credibility is insufficient, questions regarding relevance of the model results were also created. The questions are formulated such that they are readily answered and they are supplemented by helper questions that provide additional detail. Some responses indicate strongly that a model should not be used for decision making: these trigger a “fatal flaw” indicator. It is hoped that the use of this questionnaire, along with the three others in the series, will help disseminate what to look for in comparative effectiveness evidence, improve practices by researchers supplying these data, and ultimately facilitate their use by health care decision makers.     

Effect of ovarian endometriosis on ovulation in rabbits

To study the relationship between endometriosis and ovulatory dysfunction, we induced ovarian endometriosis in the rabbit model Adipose tissue was placed in the contralateral ovary as a control. Ovulation was induced with human chorionic gonadotropin, and ovulation points were counted before and after induction of endometriosis. Periovarian adhesions were graded, and ovaries were histologically examined. A significant decrease in the number of ovulation points was observed in ovaries with endometrial tissue (p = 0.001) but not in ovaries that contained adipose tissue (p = 0.095). Periovarian adhesions decreased the number of ovulation points (p less than 0.01) in ovaries that contained adipose or endometrial tissues. Multivariate analysis demonstrated that an increase in adhesion severity was correlated with a decrease in the number of ovulation points (p less than 0.05), but endometrial tissue was not (p = 0.45). We conclude that, in the rabbit model, minimal ovarian endometriosis impairs ovulation primarily through a mechanism related to periovarian adhesions.     

Impairment of neutrophil chemotactic and bactericidal function in children infected with human immunodeficiency virus type 1 and partial reversal after in vitro exposure to granulocyte-macrophage colony-stimulating factor

Because polymorphonuclear neutrophils are the most important component of host defense against bacteria, we assessed their function in 13 children with asymptomatic and 12 with symptomatic infection with human immunodeficiency virus type 1 (HIV-1), and compared their values with healthy adult control values. The functions assessed were (1) chemotaxis, (2) bacterial phagocytosis, (3) superoxide generation, and (4) bactericidal activity. Chemotaxis of polymorphonuclear neutrophils toward the chemoattractant N-formylmethionyl leucyl phenylalanine (FMLP) was significantly decreased in symptom-free infected children compared with control subjects (p less than 0.0001), but was increased in children with symptomatic infection (p less than 0.025). Bactericidal activity of the neutrophils against Staphylococcus aureus was defective in 8 of 12 children with asymptomatic infection (p = 0.016), and in 8 of 9 children with symptomatic infection (p less than 0.00001). Superoxide generation by polymorphonuclear neutrophils on stimulation with FMLP and phagocytosis of S. aureus were normal. Serum from patients with symptomatic HIV-1 infection was not as efficient in low concentrations as normal serum in the ability to opsonize S. aureus. The in vitro bactericidal defect was partially corrected by granulocyte-macrophage colony-stimulating factor (GM-CSF). The results suggest that both cellular (neutrophils) and humoral defects contribute to the increased incidence of bacterial infections in HIV-1-infected children, and that GM-CSF may improve the defective bactericidal activity of polymorphonuclear neutrophils in these patients.     

Superficially invasive carcinoma of the vagina following treatment for cervical cancer: A report of six cases

Six patients with superficially invasive squamous carcinoma of the vagina are described. All patients meet recently proposed criteria for the diagnosis of microinvasive vaginal carcinoma. The depth of invasion measured from the surface was less than 2.5 mm. There was no lymph-vascular space involvement. The invasive foci arose within a field of carcinoma in situ. Five of these six patients had previously been treated for invasive cervical cancer with pelvic radiation from 82 to 246 months before the diagnosis of vaginal carcinoma. All but one patient had the carcinoma confined to the upper one-third of the vagina. All patients were treated with a single vaginal radium application following vaginectomy. One of these six patients expired from recurrent vaginal cancer 35 months following diagnosis. During the same 17-year period, 17 other cases of Stage I epidermoid cancer of the vagina were treated which did not meet the above criteria for microinvasion. There were no statistically significant differences between these two groups with regard to age at diagnosis, history of cervical cancer, hysterectomy, or pelvic radiation or in survival. Additional experience with early vaginal carcinoma is needed before microinvasive carcinoma of the vagina should be accepted as a distinct clinical entity.     

Pseudohermaphroditism, glomerulopathy, and Wilms tumor (Drash syndrome): frequency in end-stage renal failure

The sporadic concurrence of male pseudohermaphroditism and chronic glomerulopathy is associated with an extremely high risk of Wilms tumor. We report our experience with an infant who developed this triad (Drash syndrome) and review the 21 patients described in the literature, to emphasize the importance of early diagnosis and to suggest guidelines for management. The dysgenetic gonads are always intra-abdominal and carry a 20% to 30% risk for malignancy. The external genitalia are frequently ambiguous (77%); some children are phenotypically normal females. The glomerulopathy typically leads to end-stage renal failure in infancy; the subsequent death rate has, to date, been 68%. The clinical presentation of renal disease is variable and includes congenital nephrotic syndrome (14%) and infantile nephrotic syndrome (41%); 27% of patients develop proteinuria and renal insufficiency between the ages of 1 and 3 years. The high risk of Wilms tumor (55% in this review) mandates regular tumor surveillance, and prophylactic bilateral nephrectomy and gonadectomy once irreversible renal failure develops.     

Medical care program compliance--a year 2000 recipient perspective of Medicare claims

This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.     

Selection of unrelated bone marrow donors by serology,molecular typing and cellular assays

As compared to hematopoietic stem cell transplantation (HSCT) with HLA genotypically identical donors, phenotypically matched unrelated HSCT is associated with lower survival. Serologically undisclosed HLA disparities account for the increased rate of post-transplant complications. With more than 1300 alleles currently identified, high-resolution molecular typing techniques have to be applied to distinguish the extensive degree of allelic polymorphism of the HLA system. Whereas a HLA-ABDR-serologically identical donor can be identified in the International Registry for >90% of the patients, only half of them can benefit of a highly compatible donor if donor selection is based on allele level matching for HLA-A/B/Cw/DRB1/B3/B5/DQB1 loci. During the last 10 years, we identified only approximately 20% of all known HLA alleles in the searches for our mainly Caucasoid patients. Rare alleles (i.e. alleles that represent <1% of a given serotype) do not have a major impact in patient/donor matching. Most of the incompatibilities are clustered in a limited number of serotypes that can be targeted first during the searches. However, due to linkage disequilibrium (e.g. B-Cw or DRB1-DQB1), incompatibilities at a given locus are often associated with disparities at adjacent loci. In vitro cellular assays such as the cytotoxic T-lymphocyte precursor frequency (CTLpf) analysis may contribute in discriminating functionally relevant HLA class I disparities, as well as minor antigen mismatches in case of sensitized donors. When a rare variant or an uncommon association in the patient's HLA haplotype has been found, the tissue typing laboratory may recommend considering a mismatched donor early in the search procedure instead of continuing a search with a low probability of success.     

Economic evaluation of vaccination programmes: a consensus statement focusing on viral hepatitis

The methods that have been used to estimate the clinical and economic impact of vaccination programmes are not always uniform, which makes it difficult to compare results between economic analyses. Furthermore, the relative efficiency of vaccination programmes can be sensitive to some of the more controversial aspects covered by general guidelines for the economic evaluation of healthcare programmes, such as discounting of health gains and the treatment of future unrelated costs. In view of this, we interpret some aspects of these guidelines with respect to vaccination and offer recommendations for future analyses. These recommendations include more transparency and validation, more careful choice of models (tailored to the infection and the target groups), more extensive sensitivity analyses, and for all economic evaluations (also nonvaccine related) to be in better accordance with general guidelines. We use these recommendations to interpret the evidence provided by economic evaluation applied to viral hepatitis vaccination. We conclude that universal hepatitis B vaccination (of neonates, infants or adolescents) seems to be the most optimal strategy worldwide, except in the few areas of very low endemicity, where the evidence to enable a choice between selective and universal vaccination remains inconclusive. While targeted hepatitis A vaccination seems economically unattractive, universal hepatitis A vaccination strategies have not yet been sufficiently investigated to draw general conclusions.