Increased Health Care Expenses Research Articles

Risk factors for return to work in colorectal cancer survivors.

Background: The increasing incidence of colorectal cancer among individuals in the productive age‐group has adversely affected the labor force and increased healthcare expenses in recent years. Return to work (RTW) is an important issue for these patients. In this study, we explored the factors that influence RTW and investigated the influence of RTW on survival outcomes of patients with colorectal cancer. Methods: Data of individuals (N = 4408) in active employment who were diagnosed with colorectal cancer between 2004 and 2010 were derived from 2 nationwide databases. Subjects were categorized into 2 groups according to their employment status at 5‐year follow‐up. Logistic regression analysis was performed to identify the factors associated with RTW. Survivors were further followed up for another 8 years. Propensity score matching was applied to ensure comparability between the two groups, and survival analysis was performed using the Kaplan–Meier method. Results: In multivariable regression analysis for 5‐year RTW with different characteristics, older age (OR: 0.57 [95% CI, 0.48–0.69]; p < 0.001), treatment with radiotherapy (OR: 0.69 [95% CI, 0.57–0.83]; p < 0.001), higher income (OR: 0.39 [95% CI, 0.32–0.47]; p < 0.001), medium company size (OR: 0.78 [95% CI, 0.63–0.97]; p = 0.022), and advanced pathological staging (stage I, OR: 16.20 [95% CI, 12.48–21.03]; stage II, OR: 13.12 [95% CI, 10.43–16.50]; stage III, OR: 7.68 [95% CI, 6.17–9.56]; p < 0.001 for all) revealed negative correlations with RTW. In Cox proportional hazard regression for RTW and all‐cause mortality, HR was 1.11 (95% CI, 0.80–1.54; p = 0.543) in fully adjusted model. Conclusion: Older age, treatment with radiotherapy, higher income, medium company size, and advanced pathological stage showed negative correlations with RTW. However, we observed no significant association between employment and all‐cause mortality. Further studies should include participants from different countries, ethnic groups, and patients with other cancers.

An intelligent unsupervised technique for fraud detection in health care systems

Healthcare is an essential part of people’s lives, particularly for the elderly population, and also should be economical. Medicare is one particular healthcare plan. Claims fraud is a significant contributor to increased healthcare expenses, though the effect of it could be lessened by fraud detection. In this paper, an analysis of various machine learning techniques was done to identify Medicare fraud. The isolated forest an unsupervised machine learning algorithm which improves overall performance while detecting fraud based upon outliers. The goal of this specific paper is generally to show probable dishonest providers on the ground of their allegations. Obtained results were found more promising compared to existing techniques. Around 98.76% accuracy is obtained using an isolated forest algorithm.

Consumption patterns and demand in households headed by the elderly: evidence from Brazil

PurposeThe main objective of this paper is to analyze patterns of consumption expenditure and the effects of income, prices and socioeconomic and demographic factors on demand among elderly- and young-adult-headed households in Brazil.Design/methodology/approachThe authors estimated a Quadratic Almost Ideal Demand System demand system using the main household consumption good groups – food, housing, clothing, transportation, health care and other expenses – with data from three Brazilian Household Budget surveys.FindingsThe study results showed that elderly- and young-adult-headed households have different consumption patterns. The consumption of food, transportation and health care was more price-sensitive for households headed by the elderly, while higher income increases health care expenses in elderly-headed households to a greater extent than it does in younger-headed households.Research limitations/implicationsThe limitations are due to the structure of the data used, such as the effects of seasonality and individualized demand analyses, and sample design in the estimates. However, due to the structure of the demand models, which when estimating by seemingly unrelated regressions do not allow to take into account the sample design.Practical implicationsAs a consequence of population aging, the Brazilian economy will experience changes in the composition of household consumption, mainly for food, housing, transportation and health-care-related products.Originality/valueThis paper fulfills the lack of studies that analyze the consumption patterns and how demand varies across different types of elderly-headed households in a developing country, such as Brazil.

Evaluating the diagnostic accuracy of a ctDNA methylation classifier for incidental lung nodules: protocol for a prospective, observational, and multicenter clinical trial of 10,560 cases.

BackgroundLung nodules are a diagnostic challenge. Current clinical management of lung nodule patients is inefficient and therefore causes patient misclassification, which increases healthcare expenses. However, a precise and robust lung nodule classifier to minimize discomfort for patients and healthcare costs is still lacking. The aim of the present protocol is to evaluate the effectiveness of using a liquid biopsy classifier to diagnose nodules compared to physician estimates and whether the classifier can reduce the number of unnecessary biopsies in benign cases.MethodsA prospective cohort of 10,560 patients enrolled at 23 clinical centers in China with non-calcified pulmonary nodules, ranging from 0.5 to 3 cm in diameter, indicated by LDCT or CT will be included. After signed consent forms, the participants’ pulmonary nodules will be assessed using three evaluation tools: (I) physician cancer probability estimates (II) validated lung nodule risk models, including Mayo Clinic and Veteran’s Affairs models (III) ctDNA methylation classifier previously established. Each patient will undergo LDCT/CT follow-ups for 2 to 3 years and their information and one blood sample will be collected at baseline, 3, 6, 12, 24 and 36 months. The primary study outcomes will be the diagnostic accuracy of the methylation classifier in the cohort. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) will be used to compare the diagnostic value of each testing tool in differentiating benign and malignant pulmonary nodules.DiscussionWe are conducting an observational study to explore the accuracy of using a ctDNA methylation classifier for incidental lung nodules diagnosisTrial registrationClinicaltrials.gov NCT03651986.

620-P: Improving Glycemic Control in Patients with T2D in Brazil through Tech-Enabled Low-Cost Virtual Monitoring

T2D remains a global epidemic and has become a major public health concern in Brazil, with almost 17M people living with T2D. Poor glycemic control leads to severe loss in life expectancy, quality of life and increased healthcare expenses. The main challenges to support patients with T2D in developing countries are geographical dispersion and limited budgets. The primary objective of this study is to determine whether the use of a low-cost, 100% virtual patient monitoring program, can improve disease control in patients with T2D in Brazil, using remote diabetes support through Appia’s digital platform connected to a smart BGM, coupled with remote coaches. Methods: Thirty-one participants aged 36-69 years old previously diagnosed with T2D that measure their BG levels at least 2 times per week, were recruited online and enrolled in the program. Most of them were just receiving oral medication treatment. HbA1c was measured at the beginning and at the end of the program. During the 12-week lifestyle modification program, the patients were given an intelligent BGM connected to a mobile app that stores BG measurements in the cloud. Additionally, patients were given access to a remote diabetes coach for personalized content, weekly goals setting and support. Patients did not receive medical intervention outside of their PCP. Results: The mean HbA1c was significantly reduced by 1.11% (95% CI: -1.5754 - -0.7446, p&amp;lt;0.0001) from a starting mean of 8.5% to 7.39% at the end of the program. Total average BG levels dropped from 169 mg/dL to 138 mg/dL with n=2439 readings. Also, the severe hyperglycemic events (&amp;gt;300 mg/dL) were reduced by 51.55%, without increasing level 2 (&amp;lt;54 mg/dL) and 3 hypoglycemic events. Finally, the total number of BG measurements during the program increased by 8.43% in 90 days (from 0.8/day to 0.9/day per patient). Conclusion: The combination of remote diabetes coaching with a smart BGM connected to an app was effective for improving glycemic control in patients with T2D in Brazil. Disclosure M. Carrica: Stock/Shareholder; Self; Appia. F. Valente: Consultant; Spouse/Partner; Sanofi Genzyme. Speaker’s Bureau; Self; AstraZeneca, Novo Nordisk Inc. L. Migliano: Employee; Self; Appia. Y. Lorda Dumont: None. J.E. Salles: Board Member; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk Inc.

Assessment of tolerance and acceptability between mannitol solution and polyethylene glycol as bowel preparation for colonoscopy: a three-center study

Introduction: Adequate bowel preparation is one of the most important factors related to the yield of colonoscopy. Low-quality bowel preparation has been associated with lower adenoma detection rates and increased healthcare expenses. Bowel preparation is a major impediment to undergo colonoscopy since it is perceived as an unpleasant experience by patients. Objective: This study was aimed to assess tolerance and acceptability of the bowel preparation using either polyethylene glycol (PEG) or mannitol solution. Materials and methods: We enrolled 140 patients with indications of screening for colorectal cancer or with suspected large bowel diseases. They received either mannitol solution or PEG as bowel preparation. Patients were asked to fill a questionnaire about the bowel preparation experience. Results: Patients perceived more burdensome the preparation with PEG than mannitol for the variables nausea overall experience, post-procedure discomfort, disagreeable flavor, volume ingested and cost (p&lt;0.05). A similar tolerance was reported for abdominal pain, bloating and anal irritation (p&gt;0.05). The acceptability was 82.9% and 71.4% in the Mannitol group and in the PEG group, respectively (p=0.10). Conclusion: Acceptance of the bowel preparation between mannitol solution and PEG was comparable. However, mannitol was bettertolerated by the patients in regard to most of the evaluated items.

Management of incidental nodules in lung cancer screening: ready for prime-time?

Current clinical management of lung nodule patients is inefficient and therefore causes patient misclassification, which increases healthcare expenses. A precise and robust lung nodule classifier could minimise healthcare costs and discomfort for patients. http://bit.ly/2oMIEwQ

"Not taken seriously"-A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications.

BackgroundThere is limited knowledge on the women’s experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women’s experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation.MethodsData were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13–24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis.ResultsMost participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies.ConclusionsThe findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women’s individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.

The Contemporary Role of Stents and Angioplasty for the Treatment of Infrapopliteal Disease in Critical Limb Ischemia.

Critical limb ischemia (CLI) is associated with significant morbidity, mortality, and increased health care expenses. Revascularization has a central role in the treatment of CLI. Following publication of BASIL (bypass versus angioplasty in severe ischemia of the leg) trial a decade ago, an "endovascular first" approach had gained momentum and the technologies available for endovascular therapy have exponentially increased. Both the development of technology and technique, highlighted in this review, have allowed operators to treat complex infrapopliteal lesions which are central to CLI pathology. The role of atherectomy remains controversial but for calcified lesions it has become an accepted adjunctive tool for plaque modification. The place of drug delivery technologies requires further trials. The use of a drug-coated balloon (DCB) makes intuitive sense; however, choice of excipient, lower limit of vessel size, and impact on remodeling and thrombosis remain uncertain. The optimal treatment of infrapopliteal disease remains an area of active investigation. The endpoints in CLI trials continue to be challenging and calibration of patency in relation to wound healing remains a moving target. In addition, unaccounted variables continue to confound interpretation of CLI trials-including quality and nature of wound care, status of pedal-plantar loop patency, and management of underlying diabetes and other comorbidities. In summary, these challenges will also need to be addressed as the CLI field continues to mature in the twenty-first century.

Impact of a Script-based Communication Intervention on Patient Satisfaction with Pain Management

Pain is a common complaint among hospitalized patients no matter the diagnosis. Pain has a negative effect on many aspects of a patient's life, including quality of life, sleep, and activities of daily living as well as increased health care expenses. The aim of this study was to evaluate the effectiveness of an intervention (script-based communication, use of white boards, and hourly rounding) related to pain management on patient satisfaction with nurses' management of pain. A prospective, quasi-experimental pretest–posttest design was used. Data were collected from two units that provided care for patients with a variety of medical-surgical diagnoses in a hospital located in an academic health sciences center in the southern United States. When nurses used clear and consistent communication with patients in pain, a positive effect was seen in patient satisfaction with pain management over time. This intervention was simple and effective. It could be replicated in a variety of health care organizations.

Reinternamentos Hospitalares em Portugal na Última Década

Hospital readmissions are associated with increased healthcare expenses and with higher hospital fatality rates. We aim to characterize unplanned hospital readmissions occurred within 30 days after discharge, according to its Major Diagnosis Category, hospital type and location, and patients' demographic attributes. We also intend to estimate the hospital fatality rates associated to those readmissions, as well as to study the evolution of hospital readmissions rates in the last decade (2000-2008). Moreover, we aim to characterize heart failure readmissions. We analysed a database (provided by Autoridade Central do Sistema de Saúde) containing all hospital admissions occurred in Portuguese public hospitals. In order to compare readmissions rates, we performed chi-square tests and linear-by-linear association tests. Between 2000 and 2008, there were 5 514 331 unplanned admissions, of which 4.1% corresponded to hospital readmissions, classified with the same Major Diagnosis Category of the first admission. Between 2000 and 2008, hospital readmissions rate increased continuously from 3.0% to 4.7%. Hospital fatality rate was significantly higher among readmitted cases (9.5 versus 5.6%, p < 0.001). Readmissions rates were also significantly higher among episodes involving older patients (2.6% in children versus 5.3% in the elderly) and males (4.5% versus 3.9% in females, p < 0.001), being lower in Lisbon region (2.7%) and in central hospitals (3.0%, p < 0.001). For episodes of heart failure, we found a readmissions rate of 6.7%. Most of the differences found are consistent with those described in other Western countries. Readmission episodes, whose rates have been increasing in Portugal, are associated with higher hospital fatality rates.

Health Tourism in Turkey: Opportunities and Threats

Health Tourism is becoming an upward trend in our globalised world. Health tourism can be simply defined as travelling of the individuals to other countries to seek medical care. Increased health care expenses in the West and the globalisation have led individuals to seek health care in other countries that provide affordable health care. On the other hand, wellness and anti- aging practices are also gaining ground in today’s modern world. The urge to look good on individuals as a result of the existing trends in today has also led the individual to seek advice in wellness and anti-aging. The changes in life styles and health marketing policies on wellness and anti-aging practices, lack of adequate insurances, high costs and travel means have increased the interest on health tourism. Turkey is a good destination for health tourism. Because of the high quality of service provided at an affordable cost. Also, there are no long waiting lines for foreign patients; the visa procedures are easy for most of the nations. The purpose of this paper is to outline the opportunities and threats of health tourism in Turkey. DOI: 10.5901/mjss.2013.v4n10p424

A retrospective clinical audit of blood transfusion requests in tertiary care hospital

Introduction: The inappropriate use of medical technology is a major factor in increased health care expenses and inappropriate use of blood is costly. There is a need for continuous audit of the use of products as therapy. Audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components. Aim: A retrospective clinical audit of blood transfusion requests in patients at a tertiary care hospital. Material and Methods: This retrospective clinical audit conducted at NKP salve institute of medical sciences and research center and lata mangeshkar hospital Nagpur for a period of 3 months from April 2013 to June 2013. A retrospective analysis of blood and its component requisitions in all patients from different clinical departments was reviewed regarding diagnosis, indication for transfusion, number of units requested and the speciality prescribing it. Reports of silent investigations like hemoglobin, platelet count, coagulogram was also recorded. Results: Out of 869 requisitions, 301 were for male patients and 568 were for female patients. Total number of blood components distribution request was 1188. 632 were for whole blood, 364 were for packed red cells, 182 were for FFP and 10 for platelet concentrate. Pre transfusion Hemoglobin was &gt;8 gm/dl in 273 requests. Pre transfusion hemoglobin values were not available for 192. The urgency for transfusion was mentioned on 728, indication was mentioned on 804 and diagnosis was mentioned on 755 requisition forms. Multiple blood components requests were 97. The maximum request was from Department of Obstetrics and Gynaecology. Total blood components issues were 707. Out of which 329 whole blood, 194 packed red cells, 182 FFPs and platelet concentrate were 2. Total donors were 554. Conclusion: Clinical audits helps to reduce inappropriate use of blood and blood components, avoids blood transfusion reaction and avail the deprived patients.

Economic efficiency of primary care for CVD prevention and treatment in Eastern European countries

BackgroundCardiovascular disease (CVD) is the main cause of morbidity and mortality worldwide, but it also is highly preventable. The prevention rate mainly depends on the patients’ readiness to follow recommendations and the state’s capacity to support patients. Our study aims to show that proper primary care can decrease the CVD-related morbidity rate and increase the economic efficiency of the healthcare system.Since their admission to the European Union (EU), the Eastern European countries have been in a quest to achieve the Western European standards of living. As a representative Eastern European country, Romania implemented the same strategies as the rest of Eastern Europe, reflected in the health status and lifestyle of its inhabitants. Thus, a valid health policy implemented in Romania should be valid for the rest of the Eastern European countries.MethodsBased on the data collected during the EUROASPIRE III Romania Follow Up study, the potential costs of healthcare were estimated for various cases over a 10-year time period. The total costs were split into patient-supported costs and state-supported costs. The state-supported costs were used to deduce the rate of patients with severe CVD that can be treated yearly. A statistical model for the evolution of this rate was computed based on the readiness of the patients to comply with proper primary care treatment.ResultsWe demonstrate that for patients ignoring the risks, a severe CVD has disadvantageous economic consequences, leading to increased healthcare expenses and even poverty. In contrast, performing appropriate prevention activities result in a decrease of the expenses allocated to a (eventual) CVD. In the long-term, the number of patients with severe CVD that can be treated increases as the number of patients receiving proper primary care increases.ConclusionsProper primary care can not only decrease the risk of major CVD but also decrease the healthcare costs and increase the number of patients that can be treated. Most importantly, the health standards of the EU can be achieved more rapidly when primary care is delivered appropriately.JELI18, H51

Waiting is the Hardest Part: Why the Supreme Court Should Adopt the Third Circuit's Analysis of Pay-for-Delay Settlement Agreements

In March 2013, the U.S. Supreme Court will hear Federal Trade Commission v. Watson Pharmaceuticals, Inc., giving the Court the opportunity to answer the multibillion-dollar question of whether brand-name pharmaceutical companies violate antitrust laws when they pay generic drug manufacturers to delay entering the drug market. The Supreme Court’s decision in this case could have a significant impact on rising health care costs in this country. The high cost of prescription drugs has put crippling economic pressure on the U.S. health care system. In 2010, forty-eight million Americans sacrificed filling essential drug prescriptions due to cost - often leading to life-threatening consequences and further increased health care expenses. Although many factors contribute to high drug prices, collusive settlements between brand-name pharmaceutical companies and generic drug manufacturers play a major role by presenting a barrier to lowering drug costs. Brand-name pharmaceutical companies have long been settling patent litigation by paying generic manufacturers large sums of money to drop patent lawsuits, thereby delaying generic drugs from entering the market. These settlement arrangements, known as “reverse payments” or “pay-for-delay” agreements, derive from the regulatory framework of the Drug Price Competition and Patent Term Restoration Act of 1984, otherwise known as the Hatch-Waxman Act. Though Hatch-Waxman’s goal was to increase generic drug competition in the pharmaceutical drug market while still fostering patent innovation, reverse payment settlements largely prevent timely generic drug entrance into the marketplace. As a result, drug prices remain inflated and American healthcare consumers bear the burden. According to the Federal Trade Commission (“FTC”), these anticompetitive agreements, which rose to a record number in 2012, cost consumers $3.5 billion per year. Due to the complex intersection of the regulatory scheme of Hatch-Waxman, antitrust principles, and patent law, circuit courts have reached divergent conclusions on whether reverse payment settlements are anti-competitive. Three circuit courts applied antitrust scrutiny to find that the reverse payments were unreasonable restraints of trade and violated Section 1 of the Sherman Act. Conversely, three circuit courts reasoned that a reverse payment was legal so long as it remained within the “scope of the patent.” In fact, last year, the Third Circuit reviewed the same settlement agreement as the Eleventh Circuit did in 2005 and yet reached an opposite conclusion. While the Eleventh Circuit applied the scope of the patent test to find that the payments were legal, the Third Circuit expressly rejected the scope of the patent test and found that the payments constituted prima facie evidence of an antitrust violation. Beyond settling the differences in opinion among the lower courts, the U.S. Supreme Court decision will have significant implications for the pharmaceutical industry and American consumers. This Comment contains four Parts. Part I of this Comment provides background information regarding the reverse payment settlement problem, including Congress’s intent for passing the Hatch-Waxman Act, the Act’s basic mechanisms, principles of antitrust and patent law, and the first two cases to deal with reverse payments stemming from the Act. Next, Part II discusses how the Eleventh Circuit, Second Circuit, and Federal Circuit applied the scope of the patent test to reverse payment settlement agreements, and how the Third Circuit rejected the test. Part III then analyzes these circuit court decisions, reasoning that the Third Circuit properly considered reverse payments as prima facie evidence of an unreasonable restraint of trade. Finally, Part IV proposes that the Supreme Court should adopt the Third Circuit’s reasoning and considering additional factors regarding the reasonableness of reverse payments.

Epigenetic Alterations and an Increased Frequency of Micronuclei in Women with Fibromyalgia

Fibromyalgia (FM), characterized by chronic widespread pain, fatigue, and cognitive/mood disturbances, leads to reduced workplace productivity and increased healthcare expenses. To determine if acquired epigenetic/genetic changes are associated with FM, we compared the frequency of spontaneously occurring micronuclei (MN) and genome-wide methylation patterns in women with FM (n = 10) to those seen in comparably aged healthy controls (n = 42 (MN); n = 8 (methylation)). The mean (sd) MN frequency of women with FM (51.4 (21.9)) was significantly higher than that of controls (15.8 (8.5)) (χ 2 = 45.552; df = 1; P = 1.49 × 10−11). Significant differences (n = 69 sites) in methylation patterns were observed between cases and controls considering a 5% false discovery rate. The majority of differentially methylated (DM) sites (91%) were attributable to increased values in the women with FM. The DM sites included significant biological clusters involved in neuron differentiation/nervous system development, skeletal/organ system development, and chromatin compaction. Genes associated with DM sites whose function has particular relevance to FM included BDNF, NAT15, HDAC4, PRKCA, RTN1, and PRKG1. Results support the need for future research to further examine the potential role of epigenetic and acquired chromosomal alterations as a possible biological mechanism underlying FM.

Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers

To determine incidence of pressure ulcers in patients at risk according to the Waterlow scale in intensive care units and to evaluate the effects of risk factors in critically ill patients. Pressure ulcers continue to be an important health problem that increases the risk of illness and death, extends patients' length of hospital stay and increases healthcare expenses. The study was conducted as a descriptive and prospective study. The sample consisted of 140 patients. Data were collected using a data collection form, the skin assessment instrument and the Waterlow scale. The incidence of pressure ulcers in intensive care unit patients was found to be 14.3%. The majority of pressure ulcers (74%) were grade I. The mean length of time for pressure ulcer development was found to be 10.4 (SD 1.85) days. A statistically significant difference was found in the patients for pressure ulcer development according to their level of consciousness, activity, cooperation, length of stay, Waterlow scale score and C-reactive protein level. In the multiple stepwise logistic regression analysis, the most influential factors for pressure ulcer development were determined to be length of stay and activity level. Extra care needs to be taken to prevent pressure ulcer development in intensive care unit patients who have an extended length of stay, are dependent for activities, have high Waterlow scores, are unconscious and are not cooperative. This study determined the incidence of and factors that can affect the development of pressure ulcers in intensive care unit patients who are in a high risk group for the development of pressure ulcers and presented the importance of having Turkish nurses implement interventions directed at these factors.

Assessment and Management of Patients with Obesity Hypoventilation Syndrome

Obesity hypoventilation syndrome (OHS) is characterized by obesity, daytime hypercapnia, and sleep-disordered breathing in the absence of significant lung or respiratory muscle disease. Compared with eucapnic morbidly obese patients and eucapnic patients with sleep-disordered breathing, patients with OHS have increased health care expenses and are at higher risk of developing serious cardiovascular disease leading to early mortality. Despite the significant morbidity and mortality associated with this syndrome, diagnosis and institution of effective treatment occur late in the course of the syndrome. Given that the prevalence of extreme obesity has increased considerably, it is likely that clinicians will encounter patients with OHS in their clinical practice. Therefore maintaining a high index of suspicion can lead to early recognition and treatment reducing the high burden of morbidity and mortality and related health care expenditure associated with undiagnosed and untreated OHS. In this review we define the clinical characteristics of the syndrome and review the pathophysiology, morbidity, and mortality associated with it. Last, we discuss currently available treatment modalities.

Morbid Risks of Unnecessary Red Blood Cell Transfusion in Stable Coronary Artery Bypass Graft Patients.

The persistent variability in red blood cell transfusion practice in coronary artery bypass graft (CABG) patients, despite established guidelines, suggests inappropriate use. Our objective was to determine the impact of postoperative red blood cell (RBC) transfusion in entirely stable CABG patients. We investigated a cohort of 940 stable CABG patients from the 5,065 patients enrolled in the Multicenter Study of Perioperative Ischemia Epidemiology II (EPI II) Study with (1) low to moderate risk profile; (2) postoperative hemoglobin levels ≥ 10 g/dL; (3) minimal postoperative blood loss, and (4) no evidence of any morbid event on the day of surgery. RBC transfusion was assessed during the first 24 postoperative hours and multiorgan outcomes as well as markers of resource utilization from postoperative day one to hospital discharge. Transfused patients (N =190, 20.2 %) were more likely to suffer myocardial infarction (OR, 1.89; 95 % CI, 1.08 to 3.29; P = 0.02); renal dysfunction (OR, 3.35; 95 % CI, 1.01 to 11.1; P = 0.04); renal failure requiring dialysis (OR, 4.01; 95 % CI, 0.99 to 16.2; P = 0.05); and/or harvest site wound infection (OR, 5.45; 95 % CI, 1.87 to 15.9; P = 0.001). RBC transfusion was shown to be an independent predictor of composite morbidity outcome, cardiac morbidity, and harvest site wound infection in multivariate analysis. In transfused patients, the mean duration of hospitalization was increased by 2.5 days (14.4 days vs. 11.9 days; P < 0.001). In CABG patients with low to moderate mortality risk profiles, adequate hemoglobin values and low bleeding rates, postoperative RBC transfusion is associated with an increased risk for cardiac, renal and infectious morbidity, as well as increased health care expenses, without any detectable benefit.

Pharmaceutical promotions and conflict of interest in nurse practitioner's decision making: The undiscovered country

To increase nurse practitioners' (NPs) awareness of the conflict of interest that exists between the NPs' primary goal of making the best medication choices for patients and the potentially negative impact that the pharmaceutical industry's marketing strategies have on these choices. Selected healthcare professional, philosophical, and bioethical literature was reviewed. Healthcare professionals are given gifts, dinners, and other inducements in the drug industry's effort to increase consumerism and drug sales. The current method of drug promotion increases sales but also increases healthcare expenses. Research also indicates that the pharmaceutical marketing strategies influence the judgments that NPs and other healthcare professionals make about patient care and drug prescriptions. Guidelines are presented that can reduce the likelihood that any conflict of interest that exists will influence NPs' decisions about patient care.