Academic Public Hospital Research Articles

Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital.

Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians. Clinic leadership were trained in Lean methods, protected time was dedicated to PI for a stable, interdisciplinary team, then visual management was introduced, and resident physicians were integrated into the clinic's PI initiatives. Self-assessment using the PCMH Assessment tool demonstrated improvement in core features of the PCMH model. Process outcomes also revealed successful, sustainable integration of Lean into our primary care clinic and resident training, and early findings show improvements in clinical quality outcomes. Patient survey outcomes demonstrate improvement in patient experience. Lean can be used successfully to promote PCMH transformation and create a culture of continuous PI in an academic, safety-net primary care setting.

Comparative prognostic accuracy of sepsis scores for hospital mortality in adults with suspected infection in non-ICU and ICU at an academic public hospital.

BackgroundSepsis is a global healthcare challenge and reliable tools are needed to identify patients and stratify their risk. Here we compare the prognostic accuracy of the sepsis-related organ failure assessment (SOFA), quick SOFA (qSOFA), systemic inflammatory response syndrome (SIRS), and national early warning system (NEWS) scores for hospital mortality and other outcomes amongst patients with suspected infection at an academic public hospital.Measurements and main results10,981 adult patients with suspected infection hospitalized at a U.S. academic public hospital between 2011–2017 were retrospectively identified. Primary exposures were the maximum SIRS, qSOFA, SOFA, and NEWS scores upon inclusion. Comparative prognostic accuracy for the primary outcome of hospital mortality was assessed using the area under the receiver operating characteristic curve (AUROC). Secondary outcomes included mortality in ICU versus non-ICU settings, ICU transfer, ICU length of stay (LOS) >3 days, and hospital LOS >7 days. Adjusted analyses were performed using a model of baseline risk for hospital mortality. 774 patients (7.1%) died in hospital. Discrimination for hospital mortality was highest for SOFA (AUROC 0.90 [95% CI, 0.89–0.91]), followed by NEWS (AUROC 0.85 [95% CI, 0.84–0.86]), qSOFA (AUROC 0.84 [95% CI, 0.83–0.85]), and SIRS (AUROC 0.79 [95% CI, 0.78–0.81]; p<0.001 for all comparisons). NEWS (AUROC 0.94 [95% CI, 0.93–0.95]) outperformed other scores in predicting ICU transfer (qSOFA AUROC 0.89 [95% CI, 0.87–0.91]; SOFA AUROC, 0.84 [95% CI, 0.82–0.87]; SIRS AUROC 0.81 [95% CI, 0.79–0.83]; p<0.001 for all comparisons). NEWS (AUROC 0.86 [95% CI, 0.85–0.86]) was also superior to other scores in predicting ICU LOS >3 days (SOFA AUROC 0.84 [95% CI, 0.83–0.85; qSOFA AUROC, 0.83 [95% CI, 0.83–0.84]; SIRS AUROC, 0.75 [95% CI, 0.74–0.76]; p<0.002 for all comparisons).ConclusionsMultivariate prediction scores, such as SOFA and NEWS, had greater prognostic accuracy than qSOFA or SIRS for hospital mortality, ICU transfer, and ICU length of stay. Complex sepsis scores may offer enhanced prognostic performance as compared to simple sepsis scores in inpatient hospital settings where more complex scores can be readily calculated.

Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

BackgroundDrug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment.ObjectiveEstimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis.MethodsData are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients’ medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen.ResultsWe enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment (“production cost”) in the cohort is $6,684.ConclusionsDecentralized, outpatient RR/MDR-TB care under South Africa’s 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length.

PNS189 A CAPACITY ASSESSMENT FOR A CLINICAL PHARMACY SERVICE OF A PUBLIC-SCHOOL HOSPITAL: A DISCRETE-EVENT SIMULATION CASE STUDY

Managing capacity attendance of a healthcare service is crucial to guarantee its quality and the patient safety. This study proposed a discrete-event simulation model to investigate the capacity of a clinical pharmacy department from a public-academic hospital. The service process was mapped, and the model’s operations programmed accordingly. Data was collected within the institution, and results verified. The patient's prescription was defined as the entry entity. Instead of their clinical risk, inpatients are classified according to process criteria on 6 types, which determines whether the inpatient will account with a close follow up review of a pharmacist. Results indicate that it is possible to process up to 761 prescriptions with a mean resource utilization of 82.6%. Proving that the department has enough capacity to provide its service. However, it does not guarantee that every inpatient account with a regular follow up by a pharmacist as recommended by studies to offer a higher level of service. On a simulation scenario where every inpatient account with a regular follow up review currently done manually capacity proved not to be sufficient. An electronic inpatient prioritization tool based on clinical risk was presented as a possible solution to cope with close follow up versus capacity challenge. Another simulation scenario experiment was developed to measure what would be the productivity gains.

03:18 PM Abstract No. 143 The operational, financial, and educational value of an interventional radiology clinic at an academic tertiary public hospital system

03:18 PM Abstract No. 143 The operational, financial, and educational value of an interventional radiology clinic at an academic tertiary public hospital system

Postoperative Confusion in Patients with Parkinson Disease Undergoing Deep Brain Stimulation of the Subthalamic Nucleus

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for patients with Parkinson disease. One adverse event is the development of postoperative confusion. The aim of this study was to report the incidence and associated factors of postoperative confusion after STN DBS surgery. This was a retrospective cohort study by chart review of patients with Parkinson disease who underwent STN DBS in a Brazilian public academic hospital from January 2013 to October 2017. The primary outcome was the incidence of postoperative confusion. The association of the outcome and imaging and clinical variables was evaluated. Among 49 patients who underwent STN DBS for Parkinson disease, the incidence of postoperative confusion was 26.5% (95% confidence interval 15%-41.1%). Univariate analysis identified the following variables associated with development of confusion: age (63.2 ± 7.8 years vs. 55.4 ± 9.1 years, P= 0.009), disease duration (16.5 ± 5.1 years vs. 13.2 ± 4.2 years, P= 0.027), Charlson comorbidity index (2 [interquartile range 1-3] vs. 1 [0-1 interquartile range], P= 0.002), width of the third ventricle (5.4 ± 2.1 mm vs. 4 ± 1.6 mm, P= 0.018), and cella media index (5 ± 1 vs. 5.6 ± 0.8, P= 0.018). After adjustment, Charlson comorbidity index remained significant (adjusted relative risk 1.64, 95% confidence interval 1.17-2.3, P= 0.004). The incidence of postoperative confusion in this cohort was 26.5%. After analysis of confounding factors, the Charlson comorbidity index was significantly associated with postoperative confusion.

P003 APPLYING THE TRANSITION READINESS ASSESSMENT QUESTIONNAIRE TO AN UNDERSERVED ADULT INFLAMMATORY BOWEL DISEASE POPULATION

The Transition Readiness Assessment Questionnaire (TRAQ) is a 20-item, 5-domain, validated measure of preparedness for youths with chronic illnesses to transition into adult clinics. Each question is graded on a 1-5 scale, with higher scores indicating greater skill mastery. Studies of the TRAQ in pediatric inflammatory bowel disease (IBD) patients have suggested a score of 4.5 as the threshold for readiness for adult clinics and have furthermore highlighted the impact of language, race, and socioeconomic status on successful transitions. We hypothesized that the TRAQ can similarly be used to identify those who require additional education in healthcare engagement among socioeconomically-disadvantaged adult patients with IBD. As a part of routine clinical care, the TRAQ was administered to adults with IBD presenting to Bellevue Hospital, an academic public hospital in New York City. The written survey was offered in English, Chinese, or Spanish, or was read with a phone interpreter to patients who preferred another language. In a subset of patients, a second TRAQ was administered 6 months after the initial evaluation to assess for differences in patients’ understanding and behavior over time. Demographic and clinical data were extracted from electronic medical records. Two-tailed, non-parametric t-tests were used to asses for differences between groups, with a threshold of p<0.05 set for statistical significance. Missing data or questions marked as “not applicable” by study subjects were omitted from analysis and denominators were lowered accordingly. Sixty-five patients (63% male) completed the TRAQ survey (68% English, 15% Chinese and 17% Spanish) and scored an average of 4.37. The highest scoring domain was ‘Managing daily activities’ (MDA; 4.59), while the lowest was ‘Tracking health issues’ (THI; 3.879). Overall and for each domain, there was a lower average TRAQ score for non-English speaking patients compared to English speakers that was not statistically significant. Thirty-three individuals completed a second TRAQ survey in 6 months, with no significant change in mean scores. However, when these patients were stratified based on language, we found that scores of English speakers did improve (4.42 vs 4.67, p=0.01) while scores of Non-English speakers did not (4.11 vs 4.09, p=0.94). As expected, most adult IBD patients were successful in managing activities of daily living. However, almost half of the surveyed population did not reach the threshold of healthcare utilization mastery set for pediatric patients. While TRAQ scores improved in a subset of individuals, targeted education in “tracking health issues” with special attention to non-English speaking patients may be required to improve successful utilization of healthcare services in an underserved adult IBD population.

Nonbeneficial Intensive Care: Misalignments Between Provider Assessments of Benefit and Use of Invasive Treatments.

The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians' impressions that ICU care may be nonbeneficial. Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit. There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians' impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score. Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

Employment Challenges Faced by Breast Cancer Survivors in an Upper Middle–Income Asian Setting

Background: Cancer survivorship as an area, which focuses on the health and life of an individual following cancer diagnosis and treatment is increasingly being recognized as an important component of the cancer control continuum. Advances in breast cancer detection and treatments have resulted in a growing number of patients experiencing a breast cancer diagnosis at an age when career plays an important role in their lives. Yet, very little is known on how breast cancer affects employment and return to work among survivors, particularly in low- and middle-income settings. Aim: This qualitative study aims to gain an in-depth understanding on employment challenges and motivators/barriers in return to work faced by breast cancer survivors in an upper-middle income Asian setting. Methods: Eleven focus group discussions (FGDs) were conducted with breast cancer survivors representing various ethnicities and socioeconomic backgrounds in Malaysia. Patients diagnosed one to two years prior to the study were recruited from a general public hospital, a public academic hospital and two private hospitals. Data from the FGDs were examined using thematic content analysis from the NVivo software. Results: The major themes relating to impact of cancer diagnosis on employment were “decreased work ability”, “job loss”, “long absenteeism” and “hostile work environment”. Coping strategy themes frequently mentioned to offset income loss from employment changes were “savings”, “part-time work” or financial support from “family/friends” or “social security”. However, participants were quick to highlight the insufficiency and unreliability of these strategies to cope financially in the long run. When describing their decision in choosing to return to work, participants mentioned themes such as “need money”, feeling “more happy” or having a “supportive work environment”. Nonetheless, participants emphasized the “discrimination” they faced in finding a job after active treatment. Specifically, participants' frequent need to take time-off from work for their cancer follow-ups as well as their older age were perceived as disadvantages in seeking employment when compared with younger, healthy applicants. Conclusion: It is evident that a breast cancer diagnosis severely disrupts employment and return to work in middle income settings. Multisectoral interventions are urgently required to improve the employment status of our cancer survivors, including legislative reforms to prevent discrimination. Programs supporting employment and return to work among cancer survivors should be developed and integrated in the provision of a holistic survivorship care.

Policy Recommendations to Address Financial Toxicity Following Cancer in Low- and Middle-Income Countries: One Size Does Not Fit All

Background: Evidence to guide cancer policy-making is scarce in low- and middle-income countries (LMIC). Furthermore, most economic studies in cancer have been conducted from the provider's or payer's perspective. Aim: The ASEAN Costs in Oncology Study (ACTION) was conducted to provide the essential intelligence for national policymakers and official development assistance donors to construct economically sound national cancer control plans. Methods: In the ACTION study, 9513 newly diagnosed cancer patients from eight LMIC in southeast Asia were prospectively followed-up for adverse economic outcomes up to one year after diagnosis, through serial interviews and use of cost diaries. Results: Country-specific analysis of the ACTION Study data had revealed that just within a year of diagnosis, 1 in 2 Malaysian cancer survivors had reported spending more than 30% of their annual household income for cancer related expenditures (FC: financial catastrophe). Strikingly, Malaysia, albeit being a higher income nation, appeared to have fared worse than Thailand, where only 1 in 3 cancer survivors reported FC. Nonetheless, in contrast to finding of the regional study that medical payments (drugs, hospitalization, consultation), largely explained the incidence of FC following cancer, only half of the reported catastrophic expenditures in Malaysia were attributed to medical expenditures suggesting that nonmedical payments related to cancer (e.g., travel, accommodation, childcare) was an important contributor to adverse financial outcomes. Furthermore, marked institutional variations in levels of catastrophic expenditures were observed in Malaysia, even within the public healthcare system. Proportion of patients experiencing FC in the general government hospitals was only 33% compared with 65% in the public academic hospitals. Although late stage at cancer diagnosis largely explained the increased risk of adverse economic outcomes and death, patients from low-income households remained vulnerable even when diagnosed with earlier stages. Conclusion: The findings of the ACTION Study importantly highlight the need for LMIC to undertake their own studies examining the financial impact of cancer in the population, to take affirmative actions to reduce financial loss and premature deaths associated with cancer. From the Malaysian perspective, there appears to be an urgent need to improve social support for cancer in the country, be it through government-led programs such as disability insurance and short term credit or multisectoral collaboration with civil societies, private industries, and philanthropic organizations. Key policy changes should also include prioritization of programs which would allow early detection of cancer, re-examination of the national health financing system to ensure that public funds are channeled to those who need them the most, and addressing disparities in funding between public hospitals.

Using a Positive Deviance Approach to Influence the Culture of Patient Safety Related to Infection Prevention.

BackgroundHealth care–associated infections (HAIs) are a socio-technical problem. We evaluated the impact of a social change intervention on health care personnel (HCP), called “positive deviance” (PD), on patient safety culture related to infection prevention among HCP.MethodsThis observational study was done in 6 medical wards at an 800-bed public academic hospital in the United States. Three of these wards were randomly assigned to receive PD intervention on HCP. After a retrospective 6-month baseline period, PD was implemented over 9 months, followed by 9 months of follow-up. Patient safety culture and social networks among HCP were surveyed at 6, 15, and 24 months. Rates of HAI were measured among patients.ResultsThe measured patient safety culture was steady over time at 69% aggregate percent positive responses in wards with PD vs decline from 79% to 75% in wards without PD (F statistic 10.55; P = .005). Social network maps suggested that nurses, charge nurses, medical assistants, ward managers, and ward clerks play a key role in preventing infections. Fitted time series of monthly HAI rates showed a decrease from 4.8 to 2.8 per 1000 patient-days (95% confidence interval [CI], 2.1 to 3.5) in wards without PD, and 5.0 to 2.1 per 1000 patient-days (95% CI, –0.4 to 4.5) in wards with PD.ConclusionsA positive deviance approach appeared to have a significant impact on patient safety culture among HCP who received the intervention. Social network analysis identified HCP who are likely to help disseminate infection prevention information. Systemwide interventions independent of PD resulted in HAI reduction in both intervention and control wards.

Malignant peripheral nerve sheath tumours and neurofibromatosis 1: A case series and recommendations for care

Background: The incidence of malignant peripheral nerve sheath tumours (MPNST) in patients with neurofibromatosis 1 (NF1) is significantly higher than that of the general population. NF1-associated MPNST occur at a younger age and carry a worse prognosis than sporadic MPNST.Aim: This case series describes four cases of MPNST in patients with NF1.Setting: The study was performed in a public academic hospital in the Western Cape province of South Africa.Method: Demographics, disease status, histopathology, treatment and outcome data were collected retrospectively from medical charts and through review of histological slides.Results: The median age was 36.5 years. All tumours were &gt; 5 cm at presentation and located on the trunk. One patient presented with metastatic disease. There was a mean delay of 3.5 months from presentation to initiation of treatment. Three patients underwent wide excision, with one receiving adjuvant chemotherapy and radiotherapy. At a median follow-up of 20 months from histological diagnosis only one patient was alive in clinical remission. Two patients had succumbed to progressive disease at 8 and 16 months from diagnosis and one patient with terminal metastatic disease was lost to follow-up.Conclusion: In this series the patients presented with advanced, often unresectable lesions for which single modality therapy was not curative. An adult NF1 health surveillance guideline for resource-constrained environments could lead to early diagnosis and treatment of MPNST and other complications in NF1 patients.

A nurse‐led model at public academic hospitals maintains high adherence to colorectal cancer surveillance guidelines

To examine the compliance of colorectal cancer surveillance decisions for individuals at greater risk with current evidence-based guidelines and to determine whether compliance differs between surveillance models. Prospective auditing of compliance of surveillance decisions with evidence-based guidelines (NHMRC) in two decision-making models: nurse coordinator-led decision making in public academic hospitals and physician-led decision making in private non-academic hospitals. Selected South Australian hospitals participating in the Southern Co-operative Program for the Prevention of Colorectal Cancer (SCOOP). Proportions of recall recommendations that matched NHMRC guideline recommendations (March-May 2015); numbers of surveillance colonoscopies undertaken more than 6 months ahead of schedule (January-December 2015); proportions of significant neoplasia findings during the 15 years of SCOOP operation (2000-2015). For the nurse-led/public academic hospital model, the recall interval recommendation following 398 of 410 colonoscopies (97%) with findings covered by NHMRC guidelines corresponded to the guideline recommendations; for the physician-led/private non-academic hospital model, this applied to 257 of 310 colonoscopies (83%) (P < 0.001). During 2015, 27% of colonoscopies in public academic hospitals (mean, 27 months; SD, 13 months) and 20% of those in private non-academic hospitals (mean, 23 months; SD, 12 months) were performed more than 6 months earlier than scheduled, in most cases because of patient-related factors (symptoms, faecal occult blood test results). The ratio of the numbers of high risk adenomas to cancers increased from 6.6:1 during 2001-2005 to 16:1 during 2011-2015. The nurse-led/public academic hospital model for decisions about colorectal cancer surveillance intervals achieves a high degree of compliance with guideline recommendations, which should relieve burdening of colonoscopy resources.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care.

BackgroundSafety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication.ObjectiveThis mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system.MethodsThis study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as “multitasking EHR use,” “silent EHR use,” “non-EHR multitasking,” and “focused patient-clinician talk.” Finally, we analyzed communication patterns to develop a conceptual framework.ResultsWe examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation.ConclusionsSafety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.

Clinical Characteristics and Outcomes Associated With High-Dose Intravenous Thiamine Administration in Patients With Encephalopathy

Wernicke encephalopathy is a common neuropsychiatric syndrome due to thiamine deficiency. There is no consensus regarding thiamine dosing when Wernicke encephalopathy is suspected.A longstanding dosing strategy for Wernicke encephalopathy is 100mg daily, yet updated clinical guidelines suggest using high-dose intravenous (HDIV) thiamine. To describe thiamine prescribing practices at a large, public academic hospital and investigate clinical characteristics and outcomes associated with HDIV thiamine in patients with encephalopathy who received IV thiamine. Electronic medical records of hospitalized patients who received thiamine between 4/4/2014 and 11/1/2015 were reviewed. Chi-square tests, Wilcoxon Rank Sum tests, and logistic regression were used to compare clinical variables in patients with encephalopathy who received HDIV thiamine (≥ 200mg twice daily) vs lower doses of IV thiamine. Among the total of 5236 thiamine orders, 29% (n = 1531) were IV; 10% (n = 150) of IV orders met HDIV criteria. In patients with encephalopathy who received IV thiamine (n = 432), HDIV thiamine was administered to 20% (n = 86) and only 2.1% (n = 9) received dosing consistent with Royal College of Physicians guidelines. In bivariable analyses, HDIV thiamine was associated with surgical services (p = 0.001), psychiatric consultation (p < 0.001), and decreased mortality (p = 0.004). In multivariable models, the association between HDIV thiamine and decreased in-hospital mortality did not meet statistical significance (p = 0.061). In a large, public academic hospital, guideline-concordant thiamine supplementation is rare and HDIV thiamine is infrequently prescribed to patients with encephalopathy. Further studies are needed to confirm the possible benefits of HDIV thiamine for patients with suspected thiamine-deficient encephalopathy.

PP50 Microcosting With Time-Driven Activity-Based Costing Applied On Brazilian HTA System: ECMO Case Study

Introduction:Extracorporeal circulatory membrane oxygenation (ECMO) is a technology that allows recovery of adults in cardiorespiratory failure with encouraging results, but is not available in the Brazilian universal public health system (SUS) due to high implementation costs. Time-driven activity based costing (TDABC) is applied to measure processes in an economic perspective by identifying opportunities to make processes more efficient through the reduction of resources used in each activity. The literature has explored the use of TDABC to measure costs related with clinical procedures and technologies in microcosting studies, identifying opportunities to improve the process by making it more efficient. This research measures the real costs to implement ECMO in Brazil to compare with the current public reimbursement system.Methods:This study applied TDABC using data from 6 patients to measure costs of ECMO intervention considering the public perspective in Brazil. In sequence, standard price payed by SUS was used to estimate the current reimbursement amount received by the hospital for ECMO procedure. Cost variable analysis was conducted to understand when and how patients receiving ECMO are using hospital resources. Cost data were collected from an academic public hospital using an average of 18 months (2016–2017) for the department costs.Results:The real average cost was USD 128,923. Most significant resource costs was medical staff, particularly for the three survivor patients, and the ECMO equipment presented the second highest cost. ECMO activities were separated into: before implantation of ECMO, period using ECMO, intensive care post-ECMO and rehabilitation, being the period where ECMO is the most expensive, particularly in nurse and physician costs. The SUS average was USD 31,437, which shows a difference of USD 97,485 between the real ECMO cost and the public reimbursement in Brazil.Conclusions:A critical element of the propagation of ECMO in Brazil and its reimbursement by public health system is the high cost and out-of-date standard payments by the Ministry of Health. Effort to implement a trustworthy method to guide decisions of SUS for the adoption and financing new technologies is essential to contribute to the optimization of public health policies in a country with a universal health system and limited resources dedicated to health sectors.

Quality of life in responders after palliative radiation therapy for painful bone metastases using EORTC QLQ-C30 and EORTC QLQ-BM22: results of a Brazilian cohort.

Bone metastases cause pain, suffering and impaired quality of life (QoL). Palliative radiotherapy (RT) and/or chemotherapy are effective methods in controlling pain, reducing analgesics use and improving QoL. This study goal was to investigate the changes in QoL scores among patients who responded to palliative treatment. A prospective study evaluating the role of radiation therapy in a public academic hospital in São Paulo-Brazil recorded patients' opioid use, pain score, Portuguese version of QLQ-BM22 and QLQ-C30 before and 2 months after radiotherapy. Analgesic use and pain score were used to calculate international pain response category. Overall response was defined as the sum of complete response (CR) and partial response (PR). CR was defined as pain score of 0 with no increase in analgesic intake whereas PR was defined as pain reduction ≥2 without analgesic increase or analgesic reduction in ≥25% without increase in pain at the treated site. From September 2014 to October 2015, 25 patients with bone metastases responded to RT or chemotherapy (1 CR, 24 PR). There were 8 male and 17 female patients. The median age of the 25 patients was 59 (range, 22 to 80) years old. Patient's primary cancer site was breast [11], prostate [5], lung [2], others [7]. For QLQ-BM 22, the mean scores of 4 categories at baseline were: pain site (PS) 39, pain characteristics (PC) 61, function interference (FI) 49 and psycho-social aspects (PA) 57. At 2 month follow up, the scores were PS 27, PC 37, FI 70 and PA 59. Statistical significant improvement (P<0.05) was seen in PS, PC, FI but not PA. In the QLQ-C30, the scores were not statistically different for all categories, except for pain that demonstrated a 33 point decrease in the median pain score domain (66 to 33). Responders to RT at 2 months presented improvement in BM22 and C30 pain domains, and also improvement in functional interference domain of the BM22 questionnaire.

Endometrial cancer surveillance adherence reduces utilization and subsequent costs

ObjectivesIn June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines. MethodsA retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2years pre- and 2years post-SGO guidelines. Results92 patients (n=48 pre-6/2011, n=44 post-6/2011) were identified. Mean patient age was 58years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n=13, 27% vs. n=4, 9%, p=0.03), CA125 (n=14, 29% vs. 5, 11%, p=0.035) and paps (n=34, 71% vs. n=8 vs. 18%, p<0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2years pre-guidelines, $3,054.99 2years post-guidelines). ConclusionsIn a single urban academic public hospital, after only 2years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs.

Head CT findings at a public hospital in rural Haiti

BackgroundNeuroimaging is often unavailable in low-income countries, creating challenges for precise diagnosis of neurologic disease in individual patients, and impeding acquisition of precise neuroepidemiologic data for program and policy development. MethodsWe analyzed reports from 3614 head CTs performed between July 2013 and January 2016 at Hôpital Universitaire de Mirebalais, a public academic hospital in rural Haiti, extracting patients' age, study indication, and radiologic findings. ResultsThe most common indications for head CT were headache (27%), trauma (19.9%), abnormal neurological exam (12.2%), and stroke (11.3%). The most common categories of neurologic abnormalities were traumatic (31%), vascular (25.8%), and infectious (12%). Of 291 strokes, 64% were ischemic (median age at diagnosis 60.8years, SD 17.4) and 36% were hemorrhagic (median age 52.0, SD 15.5). In patients undergoing head CT for seizures or epilepsy, 17.5% had evidence of neurocysticercosis. In patients with head trauma, 42.6% had intracranial hemorrhage or fracture. Atrophy was noted on 10% of CTs (median age 57.1; SD 23.8), and was characterized as out of proportion to age in 2% (median age 34.1, SD 15.3). ConclusionsMedian age of stroke patients in this rural low-income population is lower than in high-income countries and proportion of stroke due to intracerebral hemorrhage is higher. Neurocysticercosis is present in nearly one fifth of patients with seizures/epilepsy. These findings can inform policies and programs for prevention and treatment of neurologic disease in low-income settings.

Maternal care quality in near miss and maternal mortality in an academic public tertiary hospital in Yogyakarta, Indonesia: a retrospective cohort study

BackgroundReducing maternal mortality remains a major challenge for health care systems worldwide. The factors related to maternal mortality were extensively researched, and maternal death clusters around labour, delivery and the immediate postpartum period. Studies on the quality of maternal care in academic medical centre settings in low income countries are uncommon.MethodsA retrospective cohort study of maternal deaths was conducted in an academic public tertiary hospital in Yogyakarta, and maternal near misses were used as controls. Data were obtained from medical records from February 1, 2011 to September 30, 2012. Three groups of variables were measured: (1) timeliness of care, (2) adherence to a standard of process indicators, and (3) associated extraneous variables. Variables were analysed using logistic regression to explore their effects on maternal mortality.ResultsThe mean of triage response time and obstetric resident response time were longer in maternal deaths (8 ± 3.59 and 36.17 ± 23.48 min respectively) compared to near misses (1.29 ± 0.24 and 18.78 ± 4.85 min respectively). Near misses more frequently received oxytocin treatment than the maternal deaths (OR 0.13; 95%CI 0.02–0.77). Magnesium sulfate treatment in severe-preeclampsia or eclampsia was less given in maternal deaths although insignificant statistically (OR 0.19; 95% CI 0.03–1.47). Prophylactic antibiotic was also more frequently given in near misses than in maternal deaths though insignificant statistically (OR 0.3; 95% CI 0.06–1.56). Extraneous variables, such as caesarean sections were less performed in maternal deaths (OR 0.15; 95% CI 0.04–0.51), vaginal deliveries were more frequent in maternal deaths (OR 3.47; 95% CI 1.05–11.54), and more women in near misses were referred from other health care facilities (OR 0.09; 95% CI 0.01–0.91).ConclusionsThe near misses had relatively received better quality of care compared to the maternal deaths. The near misses had received faster response time and better treatments. Timely referral systems enabled benefits to prevent maternal death.