Increase In Rate Of Utilization Research Articles

PMD21 - An assessment of the Economic impact of the adoption of a new Mechanical fixation device along with a new skirted intra-peritoneal onlay mesh (IPOM) on Hospital costs of open Ventral Hernia repair Surgeries

PMD21 An AssessMent of the econoMic iMPAct of the ADoPtion of A new MechAnicAl fixAtion Device Along with A new skirteD intrAPeritoneAl onlAy Mesh (iPoM) on hosPitAl costs of oPen ventrAl herniA rePAir surgeries Panish J.M.1, Chekan E.2, Roy S.1 1Ethicon, Somerville, NJ, USA, 2Johnson & Johsnon (Ethicon), Cincinnati, OH, USA Objectives: Demonstrating economic value of new products is important for hospitals adoption. The combination of two devices: ETHICON SECURESTRAP® Open Absorbable Strap Fixation Device and ETHICON PHYSIOMESHTM Open Flexible Composite Mesh Device, offers a standardized approach to open IPOM repair of ventral hernia. This analysis assesses the potential economic value of using these devices when compared with other meshes and a hand-sutured fixation approach. MethOds: An economic model was developed to evaluate the budget impact to hospitals adopting ETHICON SECURESTRAPTM Open Fixation Device with ETHICON PHYSIOMESHTM Open in ventral hernia repair. A 1to 3-year time horizon was included in the Excel-based model. An increasing utilization rate for ETHICON SECURESTRAPTM Open (20% 60%), and ETHICON PHYSIOMESHTM Open (10% 30%) was assumed over 3-year horizon. Costs of the mechanical fixation device, suture supplies, mesh, OR time, anesthesia time, and potentially avoided surgical site infections were considered. The differences in total costs were calculated. Results: Based on the model inputs, a 3-year total potential saving of $240,650 was estimated for 100 annual open ventral hernia surgeries using ETHICON SECURESTRAPTM Open Fixation Device versus suture of various meshes. Over three years, although the use of ETHICON SECURESTRAPTM Open Fixation Device added $54,600 in supplies costs, this was completely offset by potential savings in OR time costs ($167,520), potential reduction in avoided surgical site infection or seroma costs due to shorter operating room time ($126,903), and potential reduction in anesthesia costs ($17,189). Similarly, a savings of $40,108 was expected in the very first year. cOnclusiOns: This analysis represents the first economic evaluation of ETHICON SECURESTRAPTM Open Fixation Device with ETHICON PHYSIOMESHTM Open in open ventral hernia surgery. Adoption of the two devices would likely result in savings for hospitals, driven by shorter procedure time and related expected clinical benefits.

Efficient hybrid white light-emitting diodes by organic-inorganic materials at different CCT from 3000K to 9000K.

The hybrid white light-emitting didoes (LED) with polyfluoren (PFO) polymer and quantum dot (QD) was investigated using dispensing method at the different correlated color temperature (CCT) for cool and warm color temperature. This result indicates that the hybrid white LED device has the higher luminous efficiency than the convention one, which could be attributed to the increased utilization rate of the UV light. Furthermore, the CIE 1931 coordinate of high quality white hybrid LED with different CCT range from 3000K to 9000K is demonstrated. Consequently, the angular-dependent CCT and the thermal issue of the hybrid white LED device were also analyzed in this study.

Illness beliefs of Chinese American immigrants with major depressive disorder in a primary care setting

Underutilization of mental health services in the U.S. is compounded among racial/ethnic minorities, especially Chinese Americans. Culturally based illness beliefs influence help-seeking behavior and may provide insights into strategies for increasing utilization rates among vulnerable populations. This is the first large descriptive study of depressed Chinese American immigrant patients’ illness beliefs using a standardized instrument. 190 depressed Chinese immigrants seeking primary care at South Cove Community Health Center completed the Explanatory Model Interview Catalogue, which probes different dimensions of illness beliefs: chief complaint, labeling of illness, stigma perception, causal attributions, and help-seeking patterns. Responses were sorted into categories by independent raters and results compared to an earlier study at the same site and using the same instrument. Contrary to prior findings that depressed Chinese individuals tend to present with primarily somatic symptoms, subjects were more likely to report chief complaints and illness labels related to depressed mood than physical symptoms. Nearly half reported they would conceal the name of their problem from others. Mean stigma levels were significantly higher than in the previous study. Most subjects identified psychological stress as the most likely cause of their problem. Chinese immigrants’ illness beliefs were notable for psychological explanations regarding their symptoms, possibly reflecting increased acceptance of Western biomedical frameworks, in accordance with recent research. However, reported stigma regarding these symptoms also increased. As Asian American immigrant populations increasingly accept psychological models of depression, stigma may become an increasingly important target for addressing disparities in mental health service utilization.

Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid

BackgroundIn 2008, Connecticut’s Medicaid program administration increased children’s dental fees to match approximately the 70th percentile of what the market fees were for dental care in 2005. These Medicaid program changes occurred at the same time as a national economic recession, which took place from 2007 through 2009. MethodsThe authors obtained Medicaid eligibility, claims, and provider data before and after the fee increase, in 2006 and 2009 through 2012, respectively. Their analysis examined changes in utilization rates, service mix, expenditures, and dentists’ participation. The authors qualitatively assessed the general impact of the recession on utilization rate changes. ResultsThe Medicaid fee increase, program improvements, and the recession resulted in a dramatic increase in utilization rates. For children continuously enrolled in Medicaid, utilization rates increased from 45.9% in 2006 to 71.6% in 2012. Rates increased across sex, race, ethnicity, and geographic areas. These increased utilization rates eliminated the disparities in access to dental services between children with private insurance and children receiving Medicaid benefits. Children enrolled in Medicaid now have utilization rates that are similar to or higher than privately insured children. Expenditures increased $62 million; this represents less than 1% of 2012 State Medicaid expenditures. Dentist participation increased by 72%. These results suggest that dentists will participate in the Medicaid program if adequately compensated, and low-income families will seek dental services. ConclusionThe Medicaid fee increase, program improvements, and the recession had a dramatic impact on reducing disparities in children’s access to dental care in Connecticut. Practical ImplicationsOne solution to the substantial disparities in access to dental care is to increase Medicaid fees to competitive levels.

Improving radiotherapy utilization rates in Ontario.

48 Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontario’s utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. Methods: CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. Results: Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. Conclusions: The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.

Determinants of enrolment and experiences of Rashtriya Swasthya Bima Yojana (RSBY) beneficiaries in Udupi district, India

Background: Morbidities have emerged as major threats to livelihoods of the poor. An estimated 150 million have been reported as spending more than 40% of their income on their health needs. Aim: To identify the determinants of enrolment and experiences of Rashtriya Swasthya Bima Yojana (RSBY) beneficiaries in Udupi district, India. Materials and Methods: A cross-sectional study was carried out in Udupi district between March and August 2012. A mixed method approach using qualitative and quantitative methods was used. The study included all households who were eligible under the RSBY scheme recognized by the Planning Commission of India as below poverty line (BPL) households and participants recruited above 18 years of age. The sample included in the study was 316 households and took into account 95% confidence interval and 20% precision. Results: Education of the household head, marital status, household size and awareness of the cost of enrollment to RSBY were seen to be significantly associated with enrollment to RSBY ( P < 0.05). Logistic regression analysis of four variables which showed statistical significance including household size, marital status, education, and prior awareness about the cost of enrollment into RSBY showed that prior knowledge of the cost of enrollment into the scheme and household size of less than five were major determinants to enrolling for RSBY. On qualitative analysis, the majority of the scheme users reported that the enrolment under RSBY had benefitted them and they are willing to renew the scheme again in the next round of enrollment. Conclusions: The awareness on scheme details among those included in the present study was found to be low. Information and education campaigns could improve involvement of both the insurers as well as the local institutions offering care and possibly increase utilization rate of RSBY.

Global Hematopoietic Stem Cell Transplantation (HSCT) At One Million: An Achievement Of Pioneers and Foreseeable Challenges For The Next Decade. A Report From The Worldwide Network For Blood and Marrow Transplantation (WBMT)

Since the first report by Nobel laureate, the late E. Donnall Thomas (NEJM, 1957, 257), HSCT has developed from an experimental to an established curative treatment for many congenital or acquired disorders of the hematopoietic system. The key steps of this success story are linked to progress in tissue typing, donor selection, supportive care and immunosuppression and fostered by intensive collaboration of physicians around the world through outcome and donor registries.The WBMT, a federation and official Non-governmental Organization of the World Health Organization, has collected HSCT activity data from its member societies and from national registries not part of an international HSCT society. Data collection did include the first transplants by ED Thomas and the first global report by M. Bortin (Transplantation 1970, 571). European data were derived from the Med A form of the European Group for Blood and Marrow Transplantation-EBMT for the years 1965-1989 and from the annual activity survey since 1990. Non-European data back to 1969 were provided by the Center for International Blood and Marrow Transplant Research-CIBMTR, with additional recent data provided by the Asia-Pacific Blood and Marrow Transplantation Group (APBMT, since 1974), the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR, since 1980), the Eastern Mediterranean Blood and Marrow Transplantation Group (EMBMT, since 1984), the Canadian Blood and Marrow Transplantation Group (CGBMT, since 2002), the Latin American Blood and Marrow Transplantation Group (LABMT, since 2009) and the African Blood and Marrow Transplant Group (AFBMT, since 2010). Double reporting was minimized by crosschecking registries and unrelated donations. Missing data from a few regions in 2012 were extrapolated from previous years assuming a 5% increase.As of December 2012, the 1450 transplant centers from 72 countries over 5 continents had reported 1.000.000 HSCT (58% autologous, 42% allogeneic). The dramatic recent increase in rate of utilization of HSCT is illustrated by the fact that there were 10.000 HSCTs worldwide by 1985, 50.000 by 1990, 100.000 by 1994, 500.000 by 2004 and 1.000.000 by December 2012. The absolute and relative contribution differed significantly with Europe providing 53%, the Americas 31%, Australasia 14% and Eastern-Mediterranean and Africa 2% to the total HSCT number (allogeneic HSCT: 45%, 32%, 20% and 3%; autologous HSCT: 58%, 31%, 10% and 1%). The increase in activity has been almost linear over the past 55 years with two exceptions, a decrease in autologous HSCT for breast cancer from 1999 especially in the Americas and a decrease in allogeneic HSCT for CML after 2000 seen everywhere except in the Eastern-Mediterranean/African region. The rise in HSCT numbers during the last decade was mainly due to an increase in allogeneic HSCT from unrelated donors; the relative increase being highest in Australasia. Recent growth was primarily due to increases in activity in existing transplant centers, rather than in the number of transplant centers. The main indications for autologous HSCT today are lymphoproliferative disorders 87% (myeloma 46% and lymphoma 41%), solid tumors 8.6% and AML 2.75%; for allogeneic HSCT leukemias 73% (AML 34.6%; ALL 16.8%; CML 4%; myelodysplastic and myeloproliferative disorders 13.3%; CLL 2.9% and other leukemias 1%), lymphoproliferative disorders 14.3% and bone marrow failure syndromes 5.5%. In 2010, cord blood was used as stem cell source in 19% of unrelated HSCT.These data were compiled through collaboration of the global HSCT community. Global collaboration has also been essential for the diffusion of HSCT as a therapy and especially for unrelated HSCT. More than 22 million unrelated donors are available today from a global network (World Marrow Donor Association, WMDA) of donor registries and cord blood banks and about 30% of unrelated HSCT involve a donor and recipient in different countries. The success of HSCT serves as a model for organ repair by the use of healthy stem cells and as a model for global cooperation in meeting the needs of an international patient population. These data also illustrate the challenges for the global medical community in providing state of the art care in regions with constrained resources and the need to find ways to make the therapy more available in order to provide better outcomes for patients with life-threatening but potentially curable diseases. Disclosures:Gluckman:Cord use: Honoraria; gamida: Honoraria.

Development of a capital investment strategy for radiation (RT) equipment in Ontario.

279 Background: To ensure appropriate access to radiation treatment (RT) for Ontario cancer patients for the next decade and that future capital investments in radiation equipment are appropriately timed and strategically placed, Cancer Care Ontario (CCO) has updated its RT Capital Investment Strategy. The strategy was designed around 4 core principles: i) recognizing treatment machine capacity should match the demand resulting from increasing cancer incidence rates and increasing utilization rates as per CCO goals; ii) keeping pace with advancing technology; iii) ensuring value for money by maximising the use of current infrastructure; and iv) minimizing costs through centralized planning and procurement processes. Methods: A multidisciplinary provincial expert panel reviewed and revised the planning parameters used to project treatment demand and required capacity (including fractions of RT per treated case, number of cases treated per hour, uptime of treatment units). The panel reviewed current practice, impact of new and emerging treatment technologies and benchmarks from other jurisdictions. To project the future demand for radiation therapy, growth in cancer incidence (by county) as well as modest improvement in RT utilization rates were assumed. Results: Recommendations included: i) moving to 12-hour treatment days in all large centres and on 50% of equipment in centres operating fewer than 6 treatment units; ii) ensuring appropriate funding for the replacement of existing RT equipment; iii) equipping constructed rooms in 4 regional cancer centers – thereby adding 6 linacs; iv) equipping swing bunkers across the province – thereby adding 10 linacs; and v) planning for the construction of new facilities to add RT capacity in 3 regions of the province. Conclusions: Funding to implement recommendations from previous capital investment strategies has resulted in an equitable distribution of RT resources across the province. We believe the planning strategies and recommendations outlined in the strategy will improve access to quality RT care as close to home as feasible for Ontario patients.

PCN39 - Economic Impact of Denosumab for Skeletal Related Event Prevention in Patients with Prostate Cancer and Bone Metastasis from a United State Managed Care Organization Perspective

To evaluate clinical and economic impact of increasing denosumab use compared to zoledronic acid (ZA) in PrCa patients with BM to a MCO. An economic model was developed to estimate clinical and economic impact to a 1-million-member US MCO of introducing denosumab as bone targeting agent (BTA) for prevention of SREs in PrCa patients with BM. Total number of patients receiving BTA was estimated based on disease prevalence and treatment eligibility in this population. The real-world SRE rates in ZA-treated patients were derived from a large commercial database and used together with the trial-based treatment effect for denosumab versus ZA to estimate the denosumab SRE rate. Total number of SREs, total SRE management medical cost, BTA drug cost, and total cost were calculated. The impact of denosumab per-member-per-month (PMPM) at increasing utilization rates was assessed by comparing to a scenario without denosumab, i.e., all patients received ZA and reported. Additionally, impact of annual increase in denosumab use was conducted. A total of 63 PrCa patients with BM received BTA. In the scenario where all eligible patients receiving ZA, an annual total number of SREs was 120. An annual denosumab use of 20%, 35% or 45% resulted in 4.2%, 7.4%, and 9.5% reduction in total SREs and 5.3%, 9.3%, and 11.9% reduction in medical costs of managing SREs, compared to all patients receiving ZA. The drug cost was partially offset by the reductions in the medical cost and the increase in total cost was minimal (1.2%-2.7%). The PMPM ranged $0.002-$0.005. Consecutive-year analysis showed $0.001 increase in PMPM with 10% denosumab utilization increase. Due to superior efficacy of denosumab versus ZA in SRE prevention in PrCa patients with BM, increased denosumab use results in medical cost reduction in a US MCO. Overall, denosumab provides additional clinical value with limited budget impact.

Home MonitoringTM technology and integrated follow-up care of ICD patients

Objective Increasing utilization rates of implantable cardioverter-defi brillators (ICDs) tend to overburden follow-up resources at the implanting electrophysiological centres (ECs). Remote monitoring technology allows physicians from diff erent institutions to simultaneously review ICD data of shared patients. We studied if an integrated follow-up care involving ECs and general cardiologists (GCs) may reduce the frequency of in-offi ce follow-ups at ECs by using remote monitoring data to identify routine checks that may be conducted at GCs.Methods and results The analysis included 109 patients (aged 63 ± 11 years, 84.4% male) followed for a cumulative study duration of 155 patient-years. The patients underwent 436 in-offi ce controls after hospital discharge: 143 (33%) at two ECs and 293 (67%) at two GCs (each cooperating with one EC). The mean duration of in-offi ce follow-up sessions was 13.7 min (EC) and 10.3 min (GC). The average distance between patients’ homes and follow-up sites was 31.6 km (EC) vs. 16.2 km (GC). Investigators considered a follow-up to be of ‘high or medium’ importance in 78% (EC) vs. 45% (GC) of all in-offi ce follow-ups. At one EC, the integrated follow-up care concept appeared highly successful, with 97% of follow-ups transferred to the corresponding GC and, on average, 103.8 km shorter patient trips per follow-up.Conclusions Integrated follow-up care guided by remote monitoring allows to direct the more signifi cant follow-ups towards ECs and routine follow-ups towards GCs. This concept may contribute to the needed adaptations of the health-care system to the rising numbers of patients with implanted devices.

Health Sector Reforms: Implications for Maternal and Child Healthcare in South Africa

Generally, public health facilities in developing countries tend to be underfunded and inefficient. In South Africa, these problems have continued even after the introduction of free maternal and child health care policy. It is argued that this policy increased utilization rate and consequently overcrowding of public health facilities. Nonetheless, long waiting times and unavailability of certain drugs continue to serve as major barriers to accessing health facilities in South Africa. Available records and our findings indicate that there is lack of consistent training for health personnel, increasing workload, inadequate physical infrastructure, resources and equipment, which have made it difficult to reduce maternal mortality rates. This paper xrays health reforms in other countries vis-a-vis propositions by international organizations and posits that the free maternal and child healthcare policy in South Africa has been formulated without considering the capacity and resources necessary to implement it. As a result, its implementation only aided in increasing access to public facilities and an improvement in utilization rates with no substantial increase in the quality of the services delivery. The paper concludes that the current health reform have the potential of reducing social exclusion, nonetheless, it must be managed carefully through supportive actions in order to avoid negative impacts on the wider health system and consequent worsening of the health system. DOI: 10.5901/mjss.2013.v4n6p593

Changes in aminoacidergic and monoaminergic neurotransmission in the hippocampus and amygdala of rats after ayahuasca ingestion

To evaluate changes in neurotransmission induced by a psychoactive beverage ayahuasca in the hippocampus and amygdala of naive rats. The level of monoamines, their main metabolites and amino acid neurotransmitters concentrations were quantified using high performance liquid chromatography (HPLC). Four groups of rats were employed: saline-treated and rats receiving 250, 500 and 800 mg/kg of ayahuasca infusion (gavage). Animals were killed 40 min after drug ingestion and the structures stored at -80 °C until HPLC assay. The data from all groups were compared using Analysis of variance and Scheffé as post test and P < 0.05 was accepted as significant. The results showed decreased concentrations of glycine (GLY) (0.13 ± 0.03 vs 0.29 ± 0.07, P < 0.001) and γ-aminobutyric acid (GABA) (1.07 ± 0.14 vs 1.73 ± 0.25, P < 0.001) in the amygdala of rats that received 500 of ayahuasca. Animals that ingested 800 mg/kg of ayahuasca also showed a reduction of GLY level (0.11 ± 0.01 vs 0.29 ± 0.07, P < 0.001) and GABA (0.98 ± 0.06 vs 1.73 ± 0.25, P < 0.001). In the hippocampus, increased GABA levels were found in rats that received all ayahuasca doses: 250 mg/kg (1.29 ± 0.19 vs 0.84 ± 0.21, P < 0.05); 500 mg/kg (2.23 ± 038 vs 084 ± 0.21, P < 0.05) and 800 mg/kg (1.98 ± 0.92 vs 0.84 ± 0.21, P < 0.05). In addition, an increased utilization rate of all monoamines was found in the amygdala after ayahuasca administration in doses: 250 mg/kg (noradrenaline: 0.16 ± 0.02 vs 0.36 ± 0.06, P < 0.01; dopamine: 0.39 ± 0.012 vs 2.39 ± 0.84, P < 0.001; serotonin: 1.02 ± 0.22 vs 4.04 ± 0.91, P < 0.001), 500 mg/kg (noradrenaline: 0.08 ± 0.02 vs 0.36 ± 0.06, P < 0.001; dopamine: 0.33 ± 0.19 vs 2.39 ± 0.84, P < 0.001; serotonin: 0.59 ± 0.08 vs 4.04 ± 0.91, P < 0.001) and 800 mg/kg (noradrenaline: 0.16 ± 0.04 vs 0.36 ± 0.06, P < 0.001; dopamine: 0.84 ± 0.65 vs 2.39 ± 0.84, P < 0.05; serotonin: 0.36 ± 0.02 vs 4.04 ± 0.91, P < 0.001). Our data suggest increased release of inhibitory amino acids by the hippocampus and an increased utilization rate of monoamines by the amygdala after different doses of ayahuasca ingestion.

Use of Outpatient Care by Juvenile Detainees Upon Community Reentry: Effects of Mental Health Screening and Referral

This study assessed rates of mental health care utilization among juvenile detainees upon community reentry and examined the impact of a mental health screening and referral program. A pre-post cohort design was used: 24 months before and after implementation of the program. The sample included 7,265 observations from 6,345 participants age 13 to 18 (first cohort, 4,812; second, 2,453). Outcomes included mental health care utilization (30 and 60 days postdetention) and recidivism (three and six months postdetention). Logistic regression models of utilization at 30 days, controlling for cohort differences with propensity scores, found that males were less likely than females to have a mental health visit (odds ratio [OR]=.54, 95% confidence interval [CI]=.45–.64, p<.01); the likelihood was also lower among black (OR=.52, CI=.44–.62, p<.01) and Hispanic (OR=.12, CI=.07–.22, p<.01) youths, compared with white youths, and among older youths (OR=.53, CI=.50–.57, p<.01) (similar results at 60 days). No overall significant differences between cohorts were found in visits at 30 (first cohort, 14%; second, 16%) and 60 (17% and 19%, respectively) days postrelease. An age interaction with cohort indicated a cohort difference among adolescents in the middle tertile (14.6–16.5 years) in utilization at 30 (first cohort, 12%; second, 17%) and 60 (16% and 21%) days. Compared with the preimplementation cohort, the postimplementation cohort had higher recidivism rates at three (first cohort, 24%; second, 31%) and six (36% and 43%) months. Connection to services upon community reentry was poor among detained youths. A screening and referral program was not sufficient to increase utilization rates.

Psychiatry in Germany 2012

Healthcare in Germany is characterized by a dichotomy of a private and a public healthcare sector, which also pertains to mental healthcare. While the prevalence figures of mental disorders in Germany remained fairly constant over the last 15 years, utilization rates of healthcare services due to mental disorders increased by 70–80% including inpatient and outpatient services, sick leave cases and cases of early retirement due to mental disorders. Several challenges are currently evident for mental healthcare in Germany, ranging from interesting a sufficient number of medical students for this field of medicine, dealing with the yet unforeseeable consequences of a novel mental hospital remuneration system, better integration of services and remuneration providers, to elucidating the causes of the increasing utilization rates. Mental healthcare research will take centre stage in addressing these challenges.

Falls, Older Adults, and the Trend in Utilization of CT in a Level I Trauma Center

The purpose of this article is to evaluate the trend in the utilization of CT for fall victims older than 55 years admitted to a level I trauma center. We used trauma registry data (1996-2006) of a level I trauma center. By using the International Classification of Disease, Ninth Revision (Clinical Modification) codes, we identified the type and frequency of CT examinations for each patient. We used negative binomial regression to evaluate the association between CT utilization rates and age, year of admission, sex, insurance status, ethnicity, ICU admission status, injury severity score, and final disposition (i.e., deceased vs alive). We used logistic regression to evaluate predictors of repeat (i.e., ≥ 2) CT scans. During the study period, the utilization rate of head, abdomen, thorax, and other body region (including spine and extremities) CT examinations increased, on average, by 7%, 16%, 14%, and 15% per year, respectively. Older age was associated with a higher utilization of head CT. Male sex and ICU admission were associated with higher utilization for all types of CT examinations. Repeat head and abdominal CT scans increased, on average, by 28% (95% CI, 20-36%) and 24% (95% CI, 2-51%) per year, respectively. We quantified the increase in utilization rates of all types of CT scans for fall victims admitted to a level I trauma center. We found a marked increase in CT use over time, both for initial as well as repeat studies, and an association between CT use and variables such as sex. Future studies should focus on the evaluation of CT appropriateness and their influence on patient outcomes.

Abstract 2968: Outcomes Of Young Acute Ischemic Stroke Over The Last Decade: Insights From Nationwide Inpatient Sample

Background: The burden of young ischemic stroke has increased over the years. However, outcomes of young patients with acute ischemic stroke (AIS) remain unknown. Over the last decade, with increasing utilization rate of iv tpa, our objective was to evaluate trends in survival and discharge outcomes of young AIS patients in the United States. Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Nationwide estimates of deaths and discharge destination were calculated for each year within the young AIS subset. The Cochrane Armitage test was used to assess trend across the years Results: From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Out of that, 204,703 (4.16%) were young patients with AIS. Thrombolysis in young ischemic stroke increased from 354 (1.84% of young AIS) in 2001 to 1237 (4.97%) in 2009 (p&lt;0.0001). There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend p= 0.027). Discharge to home or home with home health did not show any significant change (trend p= 0.52). Discharge to rehabilitation facilities showed significant increase over the years, 3.42% in 2002 to 12.7% in 2009 (trend p &lt;0.0001). Discharge to other facilities other than rehabilitation showed significant decrease over the years, 29.1% in 2001 to 17.8% in 2009 (trend p&lt;0.0001). Rate of intracranial hemorrhage, 2.70% in 2001 to 2.69% in 2009, did not show any significant change despite increasing use of iv tpa (trend p=0.39). Conclusion: Over the last decade, deaths from AIS among young patients have decreased. The increase in rehabilitation placement and decrease in nursing home discharges suggest improving neurologic outcomes. Modern treatments such as stroke units, thrombolysis, and mechanical thrombectomy may be responsible for the reductions in mortality and morbidity.

Total knee arthroplasty on the rise in younger patients: Are we sure that past performance will guarantee future success?

Total knee arthroplasty on the rise in younger patients: Are we sure that past performance will guarantee future success?

GIS Application System Design Applied to Information Monitoring

Abstract Natural environment information management system involves on-line instrument monitoring, data communications, database establishment, information management software development and so on. Its core lies in collecting effective and reliable environmental information, increasing utilization rate and sharing degree of environment information by advanced information technology, and maximizingly providing timely and scientific foundation for environmental monitoring and management. This thesis adopts C# plug-in application development and uses a set of complete embedded GIS component libraries and tools libraries provided by GIS Engine to finish the core of plug-in GIS application framework, namely, the design and implementation of framework host program and each functional plug-in, as well as the design and implementation of plug-in GIS application framework platform. This thesis adopts the advantages of development technique of dynamic plug-in loading configuration, quickly establishes GIS application by visualized component collaborative modeling and realizes GIS application integration. The developed platform is applicable to any application integration related to GIS application (ESRI platform) and can be as basis development platform of GIS application development.

Reimbursement for AAC Devices

Reimbursement for AAC Devices

Economic aspects of hybrid cloud infrastructure: User organization perspective

Adoption of cloud infrastructure promises enterprises numerous benefits, such as faster time-to-market and improved scalability enabled by on-demand provisioning of pooled and shared computing resources. In particular, hybrid clouds, by combining the private in-house capacity with the on-demand capacity of public clouds, promise to achieve both increased utilization rate of the in-house infrastructure and limited use of the more expensive public cloud, thereby lowering the total costs for a cloud user organization. In this paper, an analytical model of hybrid cloud costs is introduced, wherein the costs of computing and data communication are taken into account. Using this model, a cost-efficient division of the computing capacity between the private and the public portion of a hybrid cloud can be identified. By analyzing the model, it can be shown that, given fixed prices for private and public capacity, a hybrid cloud incurs the minimum costs. Furthermore, it is shown that, as the volume of data transferred to/from the public cloud increases, a greater portion of the capacity should be allocated to the private cloud. Finally, the paper illustrates analytically that, when the unit price of capacity declines with the volume of acquired capacity, a hybrid cloud may become more expensive than a private or a public cloud.