Medical Emergency Room Research Articles

Emergency department visits for interpersonal violence injuries in Udine (Friuli Venezia Giulia Region, Northern Italy)

to describe frequency, characteristics, and consequences of intentional injuries due to interpersonal violence visited at the Emergency Rooms of Udine and Cividale del Friuli (Friuli Venezia Giulia Region, North-Eastern Italy). analysis of the administrative database of the Emergency Department. in the two Emergency Departments of Udine and Cividale del Friuli, serving a 250,000-inhabitant area, all the visits due to injuries from interpersonal violence in the years 2015-2017 were analysed. number of visits because of injuries from interpersonal violence, distribution of demographic characteristics of patients, of characteristics of the events (place of occurrence, mechanism, relation with patient's occupation, involvement of persons known to the victims), of consequences (discharge diagnosis, Emergency Department management times). in three years, 1,741 visits of violence victims were recorded in the Emergency Department of the Udine area; 8.7% of patients were assigned a triage yellow tag and 1.0% a red tag. Almost one third of victims were non-Italian citizens; 14.2% of events were work-related; more than one third occurred in the home; in one third of cases, the aggressor was known to the victim; 96 people were diagnosed with fractures. The average time from start of medical care and Emergency Room discharge ranged from half an hour among white triage tags to more than three hours among yellow tags. More than 100 people experiences more than one violent episode. this is the first description of frequency, characteristics, and health impact of violence in the area of Udine, providing information useful for a targeted prevention. It also highlights the central role of the Emergency Department not only for the registration of the phenomenon, but also for the management of the acute episodes and for the prevention of recurrent events.

Factors related to the patient safety climate in an emergency hospital.

Objective:to verify the relationship between the socio-demographic and work profile of the nursing professionals and the patient safety climate in a public emergency hospital.Method:a cross-sectional study carried out with 177 nursing professionals from a public emergency hospital. For data collection, the Safety Attitudes Questionnaire - Short Form 2006 was used, validated and cross-culturally adapted to the Portuguese language. To check the factors related to the instrument’s domains, bivariate and multivariate analyses were performed.Results:working in the medical and surgical clinic or emergency room, on a night shift, and having the intention to leave nursing, reduced the general safety climate in the multiple regression analysis. The younger professionals, with less than four years in the institution, and those who worked in the night shift had a lower safety climate related to the perception of the management. On the other hand, having a work contract with a hired worker improved the general safety climate and workplace satisfaction.Conclusion:identifying predictors on patient safety scores is an important management tool that allows diagnosing, planning and executing activities from the domains that need to be improved.

Comparative study of pattern of head injury in a rural community hospital and a tertiary care hospital

Background: The objective of the study was to compare clinical patterns of head injuries in reference to the Glasgow coma scale including neurological examination and also to determine morbidity and mortality in head injury patients admitted to a nodal tertiary care hospital and a rural community hospital.Methods: This prospective study was done at the emergency department of Kasturba Hospital attached to Mahatma Gandhi Institute of Medical Sciences and Sushrut Hospital, Maharashtra on a total of 1000 cases during one-year study duration. The severity of the head injury was analysed using a Glasgow coma scale and outcome in terms of management and death was assessed.Results: Out of 1000 cases with head injuries, 900 cases were admitted in tertiary care hospital and 100 cases in a rural hospital. A significant difference was observed in terms of age group (p=0.01), mode of trauma (p=0.04) and symptoms (p=0.03) among the patients admitted with head injuries in both hospitals. The mortality rate was 1% and 3% in tertiary care and rural hospitals respectively.Conclusions: Head injuries are predominantly affecting the male population and most of them are due to road traffic accidents. Early assistance of medical aid and emergency room care results in good outcomes with minimal deaths.

Clinical information and guidance shared via a patient infotainment system can reduce hospital stay and maintain 2 medical quality for total knee arthroplasty: A single-blinded quasi-randomised controlled trial

BackgroundThe demand for total knee arthroplasty is increasing worldwide. Optimising results and meeting patients’ expectations are more challenging than before, because the length of hospitalisation has markedly reduced and the standard care processes have been accelerated. We incorporated an interactive patient infotainment system into the standard clinical pathway for total knee arthroplasty in the hope of improving patients’ length of stay. ObjectivesTo analyse whether incorporation of an interactive infotainment system reduced the length of stay and improved the quality of medical care (in terms of number of medical orders and emergency room returns). DesignA prospective, quasi-randomised controlled trial. Participants and SettingData of 86 patients hospitalised for a unilateral total knee arthroplasty at a medical centre in Taiwan were analysed. MethodsFrom January 2017 to July 2017, 86 patients who underwent unilateral total knee arthroplasty and were cared for under a standard clinical pathway were included. The study group (41 patients) had access to electronic programs and video demonstrations related to health literacy, physical therapy, home care and precautions following total knee arthroplasty via a patient infotainment system, while the control group (45 patients) did not. Hospital course, quality indices, in-hospital medical costs, returns to the emergency room and readmission at 30 or 90 days were analysed and compared between the two groups of patients. ResultsThe study group had a shorter length of stay (4.4 vs. 4.8 days, mean differences [MD] = −0.37, 95% CI −0.71 to −0.03, p = 0.026) and fewer medical orders (109 vs 111 orders, MD = −1.86, 95% confidence intervals (CI) −3.58 to −0.15, p = 0.047) as compared with the control group. The incidences of emergency room return and readmission to the hospital at 30 or 90 days were comparable between the two groups. No difference in the total medical cost was found between the two groups, with only the cost of laboratory tests in the study group being significantly lower than that in the control group ($144 vs. $163, MD = −21.7, 95% CI −41.0 to −2.25, p = 0.007). ConclusionsThe incorporation of a patient infotainment system into the standard clinical pathway for total knee arthroplasty can efficiently reduce the length of hospital stay and maintain the quality of medical care. Further studies on improvement of patient medical literacy with the help of the infotainment system would be of interest in order to improve clinical practice and patient satisfaction. Registration numberNCT03788798 Tweetable abstractA patient infotainment system can reduce hospital stay and maintain medical quality for total knee arthroplasty

42936 pathogens from Canadian hospitals: 10 years of results (2007-16) from the CANWARD surveillance study.

The CANWARD surveillance study was established in 2007 to annually assess the in vitro susceptibilities of a variety of antimicrobial agents against bacterial pathogens isolated from patients receiving care in Canadian hospitals. 42 936 pathogens were received and CLSI broth microdilution testing was performed on 37 355 bacterial isolates. Limited patient demographic data submitted with each isolate were collated and analysed. Of the isolates tested, 43.5%, 33.1%, 13.2% and 10.2% were from blood, respiratory, urine and wound specimens, respectively; 29.9%, 24.8%, 19.0%, 18.1% and 8.2% of isolates were from patients in medical wards, emergency rooms, ICUs, hospital clinics and surgical wards. Patient demographics associated with the isolates were: 54.6% male/45.4% female; 13.1% patients aged ≤17 years, 44.3% 18-64 years and 42.7% ≥65 years. The three most common pathogens were Staphylococcus aureus (21.2%, both methicillin-susceptible and MRSA), Escherichia coli (19.6%) and Pseudomonas aeruginosa (9.0%). E. coli were most susceptible to meropenem and tigecycline (99.9%), ertapenem and colistin (99.8%), amikacin (99.7%) and ceftolozane/tazobactam and plazomicin (99.6%). Twenty-three percent of S. aureus were MRSA. MRSA were most susceptible to ceftobiprole, linezolid and telavancin (100%), daptomycin (99.9%), vancomycin (99.8%) and tigecycline (99.2%). P. aeruginosa were most susceptible to ceftolozane/tazobactam (98.3%) and colistin (95.0%). The CANWARD surveillance study has provided 10 years of reference antimicrobial susceptibility testing data on pathogens commonly causing infections in patients attending Canadian hospitals.

Abstract TP494: A Continuous Monitoring Led by a Nurse Working Group Plays a Key Role in the Improvement of Acute Ischemic Stroke Workflow-Metrics

Background and Purpose: In the workflow process for the management of acute ischemic stroke (AIS) patients, time is critical to improve functional outcome. Based on the recent 2018 AHA ASA guidelines, median door-to-imaging (DTI) time should be less than 20 minutes and median door-to-needle (DTN) time for tPA administration less than 60 minutes. Our comprehensive stroke center mostly recruits suspected AIS patients following a “mother ship” approach with systematic emergency medical services pre-notification and emergency room by-pass. Based on this specific patient’s care approach, the purpose of our study was to evaluate our capacity to get with the guidelines (GWTG) and to shorten our DTN/DTI times. Methods: In our stroke center, the stroke alert follows a workflow including 15 time-points from call notification to cath lab access. The stroke team work during the stroke alert was evaluated, during two periods of time (oct-to-march and april-to-august) based on its capacity to comply with DTI and DTN recommended median times. Continuous improvement of the workflow was based on prospective data collection analysis and interpretation by a working group led by nurses focusing on knowledge, organization and leadership difficulties identification. Results: From october 2017 to august 2018, 501 stroke alerts were identified in our comprehensive stroke center. Of these, 425 (85%) cases were analyzed. A total of 81 (19%) of the suspected AIS patients received tPA, 44 (10.3%) were treated with combined tPA infusion and thrombectomy and 44 (10.3%) with thrombectomy alone. Median DTI time was 15 min (3-62), median DTN time for tPA administration was 44 min (21-87), median door-to-cath lab time was 64 min (23-140). DTI median time improved significantly between the two time-periods (15,5 (3-62), vs 15(3-50), p= 0,01). Neither DTN time nor door-to-cath lab room time changed significantly during the studied time periods. Conclusion: Our comprehensive stroke center fulfilled the 2018 AHA ASA guidelines for DTI and DTN times. Under the supervision of a nurse working group, shortening of DTI times could be achieved. These findings support the key role of nurses working groups focusing on knowledge and management to improve stroke alert workflow, and finally patient care.

Characteristics of patients who visit the dental emergency room in a dental college hospital.

BackgroundEmergencies in dentistry can be classified as medical and dental. Medical emergencies occur mainly during dental treatment in patients with a systemic disease. Dental emergency departments are largely divided into dental emergency rooms located in dental college hospitals and medical emergency rooms located in medical institutions. This study aimed to analyze the characteristics of and provide help to dental emergency patients in a dental hospital.MethodsOverall, 1806 patients admitted to a dental emergency room at Yonsei University Dental Hospital for 1 year were included. The data collection period was from October 1, 2014 to September 30, 2015. An investigator reviewed medical records from the electronic medical record (EMR) system and radiographs.ResultsThe patients were 1,070 men and 736 women. The sex ratio was 1.45:1. The commonest age group was of 0–9 years, including 451 (25.0%) patients, followed by 20–29 years, including 353 (19.5%) patients, and 30–39 years, including 277 (15.3%) patients. Of the 108 patients transferred to the Severance emergency department, 81 had trauma, 19 were in pain, 4 were bleeding, and 4 had other complaints. Among chief complaints, 1,079 patients (60.3%) had trauma, 564 (31.5%) had pain, and 75 (4.2%) had bleeding. Twenty-three cases (1.3%) were caused by temporomandibular disorder (TMD).ConclusionDentists should be able to adequately assess patients in a dental emergency room and treat trauma, pain, and bleeding.

Extensive Distribution of the Lyme Disease Bacterium, Borrelia burgdorferi Sensu Lato, in Multiple Tick Species Parasitizing Avian and Mammalian Hosts across Canada

Lyme disease, caused by the spirochetal bacterium, Borrelia burgdorferi sensu lato (Bbsl), is typically transmitted by hard-bodied ticks (Acari: Ixodidae). Whenever this tick-borne zoonosis is mentioned in medical clinics and emergency rooms, it sparks a firestorm of controversy. Denial often sets in, and healthcare practitioners dismiss the fact that this pathogenic spirochetosis is present in their area. For distribution of Bbsl across Canada, we conducted a 4-year, tick–host study (2013–2016), and collected ticks from avian and mammalian hosts from Atlantic Canada to the West Coast. Overall, 1265 ticks representing 27 tick species belonging to four genera were collected. Of the 18 tick species tested, 15 species (83%) were positive for Bbsl and, of these infected ticks, 6 species bite humans. Overall, 13 of 18 tick species tested are human-biting ticks. Our data suggest that a 6-tick, enzootic maintenance cycle of Bbsl is present in southwestern B.C., and five of these tick species bite humans. Biogeographically, the groundhog tick, Ixodes cookei, has extended its home range from central and eastern Canada to southwestern British Columbia (B.C.). We posit that the Fox Sparrow, Passerella iliaca, is a reservoir-competent host for Bbsl. The Bay-breasted Warbler, Setophaga castanea, and the Tennessee Warbler, Vermivora peregrina, are new host records for the blacklegged tick, Ixodes scapularis. We provide the first report of a Bbsl-positive Amblyomma longirostre larva parasitizing a bird; this bird parasitism suggests that a Willow Flycatcher is a competent reservoir of Bbsl. Our findings show that Bbsl is present in all provinces, and that multiple tick species are implicated in the enzootic maintenance cycle of this pathogen. Ultimately, Bbsl poses a serious public health contagion Canada-wide.

Using the Collective System Design Methodology to Improve a Medical Center Emergency Room Performance.

Emergency Room (ER) crowding is one of the more complex issues in the healthcare system worldwide. Crowding gives rise to long ER waiting times, patient dissatisfaction, and negative effects on a healthcare systems' performance. This paper focuses on the utilization of the Collective System Design (CSD) methodology to optimize the performance of an ER, which is of principal importance both from a life-threatening and an economic standpoint. The CSD technique is applied to detect areas of deficiency and to identify the functional requirements of the system to address those issues. The ER and system engineering specialists' team gathered data from the electronic medical center log and their system observation. The team determined the functional requirements and effective solutions, and implemented a continuous improvement plan to enhance ER performance. From a statistical standpoint, a significant decrease in the median of the door-to-doctor time measure (27min vs 13min) and a substantial improvement in the patients' level of satisfaction with the quality of health care (20th percentile vs 41th percentile) were observed after the implementation of the CSD methodology. The CSD methodology augments the implementation of lean tools by providing a language for defining the requirements and corresponding solutions for a system design. Using the CSD methodology, results in a significant increase in the ER's capacity to treat patients efficiently.

Intensive Care Need and Its Predictors Among Patients Admitted With Acute on Chronic Liver Failure: A Retrospective Study From a Single Tertiary Care Center

Introduction: Acute-on-chronic liver failure (ACLF) among patients with chronic liver disease has high mortality secondary to organ failure (OF). Data on need for ICU care in ACLF patients are scanty. Methods: Medical charts were reviewed on patients admitted to a tertiary care center with discharge diagnosis of cirrhosis to analyze ACLF patients (based on organ failures Gastroenterology 2013; 144: 1426-37) for ICU care and its predictors. ICU transfer was initiated based on criteria as for any other patient on medical floor or emergency room. Results: Of 567 patients discharged with cirrhosis diagnosis between 7/1/16 and 6/30/17, 123 (22%) met criteria for ACLF diagnosis (mean age 55yrs., 50% males, 79% white, 54% alcoholic cirrhosis, 80% with prior decompensation, mean MELD score 27, mean white cell count 10.6/cmm), precipitated by alcoholic hepatitis (33%), infection (31%), GI bleed (15%), and unknown in 20%. Coagulation failure (INR>2.5) was most common in 91 (74%) followed by renal (creatinine >2 mg/dL or dialysis) in 80 (65%), brain (grade III-IV encephalopathy) in 64 (52%), liver (bilirubin> 12 mg/dL) in 60 (49%), lung (mechanical ventilation) in 42 (34%), and heart (use of pressor) in 40 (33%). Of 123 ACLF patients, 66 (54%) needed ICU care. Of these, 50 were ACLF grade 3, 12 grade 2, and 4 grade 1 (p= Conclusion: ICU care is frequently needed among ACLF patients, with higher inpatient mortality and use of hospital resources. Studies are needed to develop criteria for early ICU transfer among ACLF patients, as basis for improving outcomes of patients with ACLF.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.

Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study

ObjectivesCompare gender disparities in ST-elevation myocardial infarction (STEMI) regarding first medical contact (FMC) and prehospital delay times and explore factors associated with prehospital delay in men and women separately.DesignCross-sectional study...

Association of Maternal Depressive Symptoms and Offspring Physical Health in Low-Income Families.

Objectives The present study sought to examine the association between maternal depressive symptoms and characteristics of offspring physical health, including health status, health behaviors, and healthcare utilization, among low-income families. Maternal engagement was explored as a mediator of observed effects. Methods Cross-sectional survey data from a community sample of 4589 low-income women and their preschool-age children participating in the WIC program in Los Angeles County were analyzed using logistic, Poisson, and zero-inflated negative binomial regression. Mediation was tested via conditional process analyses. Results After controlling for the effects of demographic characteristics including maternal health insurance coverage, employment status, education, and preferred language, children of depressed women (N = 1025) were significantly more likely than children of non-depressed women (N = 3564) to receive a "poor" or "fair" maternal rating of general health (OR 2.34), eat fewer vegetables (IRR: 0.94) more sweets (IRR: 1.20) and sugary drinks daily (IRR: 1.32), and consume fast food more often (OR 1.21). These children were also less likely to have health insurance (OR 1.59) and more likely to receive medical care from a public medical clinic or hospital emergency room (OR 1.30). Reduced maternal engagement partially mediated associations between maternal depressive symptoms and several child health outcomes including poor diet, health insurance coverage, and use of public medical services. Conclusions for Practice Maternal depressive symptoms are associated with poor health among preschool-age children in low-income families. Prevention, screening, and treatment efforts aimed at reducing the prevalence of maternal depression may positively affect young children's health.

Outpatient Total Ankle Arthroplasty is a Safe Alternative to Traditional Inpatient Admission or Overnight Observation

Category: Ankle, Ankle Arthritis Introduction/Purpose: Safe and cost-effective health care has become a priority in the United States. Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) compared with overnight or more extended hospital stay, with regard to 90-day global period medical and surgical complications, reoperations, readmissions or emergency room visits, and pain control. Methods: The medical records of patients who underwent TAA over a three-and-a-half-year period with a single, fellowship- trained orthopedic foot and ankle surgeon were retrospectively reviewed. Outcome measures included surgical complications, adverse medical events, readmission or emergency room visit for any reason, reoperation within the first 90 days following surgery, any notation of phone call or email to the surgeon’s office prior to first-operative visit regarding pain or other issues, Visual Analog Scale (VAS) pain score at the first post-operative visit, and need for narcotic refill. Outcomes were assessed by admission status; outpatient (discharge home the same day), overnight observation, or inpatient admission (hospital stay of two or more nights). Standard statistical analysis was used and p < 0.05 was considered significant. Results: 82 patients underwent TAA who met inclusion criteria. No statistical differences were found between outpatient, overnight observation, and inpatient admission groups with regard to age, preoperative American Society of Anesthesiologists (ASA) score, gender, laterality, operative indication, or additional number of procedures. A significant difference in complication rate was seen between the three groups (p=0.02), but not rate of readmission or reoperation. Five of sixteen patients (31.2%) admitted for two or more nights following surgery had a complication after discharge versus four of sixty-six (6.1%) in those who were outpatient or admitted overnight (p=0.01). There were no differences in frequency of post-operative phone calls, narcotic refills, or VAS pain score at the first post-operative visit. There were no adverse medical events in any group. Conclusion: With appropriate patient selection and proper instruction, TAA may be performed safely in the outpatient setting. Patients who were discharged home the day of surgery did not require more attention or care in the immediate post-operative period and adverse medical events did not occur. The inpatient group was more likely to have complications, but these mostly consisted of minor superficial wound problems, which may be attributed to patient factors unaccounted for in this study. As health care policy continues to evolve, efficient and cost-effective practices will be a priority and should be further studied.

Safety of Outpatient Total Ankle Arthroplasty vs Traditional Inpatient Admission or Overnight Observation.

Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) as compared with overnight or extended inpatient stay, with regard to 90-day medical and operative complications, reoperations, readmissions or emergency room visits, and pain control. The medical records of patients who underwent TAA with 1 fellowship-trained orthopedic foot and ankle surgeon were reviewed. Outcome measures included operative complications, adverse medical events, readmission or emergency room visit for any reason, or reoperation within 90 days following surgery; surgeon's office contact before first postoperative visit regarding pain or other issues; visual analog scale pain score at the first postoperative visit; and need for narcotic refill. Outcomes were assessed by admission status: outpatient, overnight observation, or inpatient admission. Standard statistical analysis was used, and P < .05 was considered significant. Eighty-one patients underwent TAA who met inclusion criteria, and 8 had a complication (10%). A significant difference in complication rate was seen among groups ( P = .01) but not rate of readmission or reoperation. Of 16 patients, 5 (31%) who were admitted for 2 or more nights following surgery had a complication, as opposed to 3 of 65 (5%) who were outpatient or admitted overnight ( P = .01). There were no differences in frequency of postoperative phone calls, narcotic refills, or visual analog scale pain scores at the first postoperative visit. There were no adverse medical events. With proper instruction, TAA was performed safely in the outpatient setting. As health care policy continues to evolve in the United States, safe and efficient practices will remain a priority. Level III, retrospective comparative study.

Budget impact of perampanel as adjunctive treatment of uncontrolled partial-onset and primary generalized tonic-clonic seizures in the United States.

To evaluate the budget impact (BI) of adopting perampanel for adjunctive treatment of partial-onset seizures (POS), with or without secondarily generalized seizures, and the adjunctive treatment of primary generalized tonic-clonic seizures (PGTCS) in patients 12years or older in the United States. A BI model was developed to estimate the potential BI of adopting adjunctive perampanel from a US payer (direct costs only) and societal (direct and indirect costs) perspective over a 5-year period. Efficacy data for perampanel and antiepileptic drug (AED) maintenance therapy were obtained from perampanel phase III clinical trials. Drug, direct medical (healthcare provider, emergency room, and hospitalizations), and indirect (productivity loss) costs were obtained from appropriate sources (e.g., AnalySource® Online [wholesale acquisition costs], 2013 Optum Insight Clinformatics Database [market share percentages, direct medical costs per unit], and 2011-2013 National Health and Wellness Survey [NHWS; healthcare resource utilization, overall work impairment, and baseline distribution of patients across the 4 health states]). Mapping of seizure frequency to medical resource utilization and work impairment was obtained from Kantar Health's NHWS. In a hypothetical health plan of 1 million members, 660 (0.066%) members ≥12years old had uncontrolled POS (395 [59.8%]) or PGTCS (265 [40.2%]). During the first 5years of adoption of perampanel, absolute BI (including drug, direct medical, and indirect costs) was $852, $2124, $3855, $5318, and $6397, respectively, for a cumulative absolute BI of $18,545. Drug cost was estimated to increase by $13,888, $34,646, $62,863, $86,728, and $104,326, respectively; however, this cost would be mostly offset by decreases in direct medical ($5041, $12,576, $22,818, $31,481, and $37,869, respectively) and indirect ($7995, $19,946, $36,190, $49,929, and $60,060, respectively) costs. Total per-member-per-month cost (drug and direct medical costs) was estimated to increase by $0.0007, $0.0018, $0.0033, $0.0046, and $0.0055 from years 1 to 5. Based on results of this BI model, increased cost of adopting perampanel in a health plan of 1 million members would be minimal for payers, and societal costs would be close to neutral.

Patient Feedback on Pharmacist Prescribing for Minor Ailments in a Canadian Province

Background: Pharmacists have been given authority in many Canadian provinces to go beyond simply recommending over-the-counter medicines to patients with minor ailments. In Saskatchewan, they can prescribe medicines normally under the sole control of physicians for 17 conditions. An evaluation program is underway to assess the value of the program. Methods: Adults were recruited over a one-year period and were eligible for inclusion if prescribed an agent for an applicable condition. Pharmacists from 40 pharmacies participated in identifying people who received the service. Of patients agreeing to participate, a link to an online survey was provided. The survey included items on clinical improvement, care options, and patient confidence in knowing when to seek a physician for a minor ailment. Results: Forty-eight people were involved in prescribing encounters, with the majority seeking help for themselves. All but one saw their symptoms improve subsequent to pharmacist assistance, most often to a significant extent. Satisfaction with the service was high. Convenience and trust in pharmacists were primary reasons for choosing the service over medical care (rather than an issue potentially more worrisome such as not having a family physician). Had this service not been in place, 30.6% of those asking for help would have gone to a medical clinic or emergency room. Seventy-five percent were (at least) very confident in knowing when to seek a physician (rather than a pharmacist) for such conditions. Conclusion: Information on the clinical outcomes of pharmacist-led minor ailment care is starting to accrue in Saskatchewan. While the numbers are extremely low to date, what has become available suggests the service is of value to the citizens of the province, it is chosen for appropriate reasons, and is of an acceptable standard of care.&#x0D; Conflict of Interest&#x0D; We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties. However, the authors are pharmacists licensed within the province and bring this perspective to this evaluation of a pharmacy-based program.&#x0D; &#x0D; Type: Original Research

Association between parental access to paid sick leave and children's access to and use of healthcare services.

We examined the association between parental access to paid sick leave (PPSL) and children's use of preventive care and reduced likelihood of delayed medical care and emergency room (ER) visits. We used the child sample of the National Health Interview Survey data (linked to the adult and family samples) from 2011 through 2015 and logistic and negative binomial regression models. Controlling for covariates, the odds of children with PPSL receiving flu vaccination were 12.5% [95%CI: 1.06-1.19] higher and receiving annual medical checkups were 13.2% [95%CI: 1.04-1.23] higher than those of children without PPSL. With PPSL, the odds of children receiving delayed medical care because of time mismatch were 13.3% [95%CI: 0.76-0.98] lower, and being taken to ER were 53.6% [95%CI: 0.27-0.81] lower than those of children without PPSL. PPSL was associated with 11% [95%CI: 0.82-0.97] fewer ER visits per year. PPSL may improve children's access and use of healthcare services and reduce the number of ER visits. Am. J. Ind. Med. 60:276-284, 2017. © 2017 Wiley Periodicals, Inc.

Patient Feedback on Pharmacist Prescribing for Minor Ailments in a Canadian Province

Background: Pharmacists have been given authority in many Canadian provinces to go beyond simply recommending over-the-counter medicines to patients with minor ailments. In Saskatchewan, they can prescribe medicines normally under the sole control of physicians for 17 conditions. An evaluation program is underway to assess the value of the program. Methods: Adults were recruited over a one-year period and were eligible for inclusion if prescribed an agent for an applicable condition. Pharmacists from 40 pharmacies participated in identifying people who received the service. Of patients agreeing to participate, a link to an online survey was provided. The survey included items on clinical improvement, care options, and patient confidence in knowing when to seek a physician for a minor ailment. Results: Forty-eight people were involved in prescribing encounters, with the majority seeking help for themselves. All but one saw their symptoms improve subsequent to pharmacist assistance, most often to a significant extent. Satisfaction with the service was high. Convenience and trust in pharmacists were primary reasons for choosing the service over medical care (rather than an issue potentially more worrisome such as not having a family physician). Had this service not been in place, 30.6% of those asking for help would have gone to a medical clinic or emergency room. Seventy-five percent were (at least) very confident in knowing when to seek a physician (rather than a pharmacist) for such conditions. Conclusion: Information on the clinical outcomes of pharmacist-led minor ailment care is starting to accrue in Saskatchewan. While the numbers are extremely low to date, what has become available suggests the service is of value to the citizens of the province, it is chosen for appropriate reasons, and is of an acceptable standard of care. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties. However, the authors are pharmacists licensed within the province and bring this perspective to this evaluation of a pharmacy-based program. Type: Original Research

Long-Term Outcomes After Residential Substance Use Treatment: Relapse, Morbidity, and Mortality.

A cohort of 207 veterans admitted to a residential substance use treatment program was followed for 5 years following discharge to determine factors associated with reduced relapse or mortality following discharge. Subsequent utilization of medical and psychiatric hospitalization and emergency room utilization was also examined. Retrospective chart review was conducted using demographic, diagnostic, and prior treatment as independent variables. Dependent variables included aftercare compliance and subsequent morbidity as measured by relapse, emergency room visits, subsequent hospitalizations, and mortality. Cox proportional hazards models were used to examine factors associated with relapse and mortality. Aftercare attendance was higher in those who completed treatment (p < 0.01). Factors associated with higher risk of relapse included comorbid disorders, failure to complete the index residential substance use treatment program, and psychiatric rehospitalization. Factors associated with higher mortality included failure to complete residential substance use treatment, longer medical rehospitalization, and nicotine dependence. Longer psychiatric rehospitalization was associated with a lower risk of mortality. Comorbid psychiatric conditions and failure to complete residential substance use treatment were associated with higher relapse. Limitations include that this population has severe substance use disorder, that subjective report of symptom severity was not assessed and that attendance at Alcoholics Anonymous aftercare was not surveyed.