Public Emergency Department Research Articles

Sex- and Age-Related Impact of the COVID-19 Pandemic on Emergency Department Visits for Chest Pain in Curitiba, Brazil

BackgroundWomen have higher mortality from acute coronary syndrome (ACS) compared with men. Women may hesitate to search for emergency care when experiencing chest pain, which delays treatment. ObjectiveOur aim was to evaluate the changes in emergency visits for chest pain according to sex and age during the COVID-19 pandemic period compared with previous years. MethodsWe collected data on chest pain visits (International Classification of Diseases, Tenth Revision, Clinical Modification codes I20 [unstable angina], I21 [myocardial infarction], and R07.1-4 [chest pain]) from all public emergency departments (EDs) in Curitiba, Brazil. We compared the weekly rates of visits per 100,000 habitants on the epidemiologic weeks 11–52 of 2020 (COVID-19 pandemic period) with the average rates of the same weeks of 2018 and 2019 using Poisson regression. ResultsFrom 2018 to 2020, 37,448 individuals presented to the ED for chest pain, of whom 8493 presented during the COVID-19 pandemic period. Compared with previous years, we observed a 23% reduction in chest pain visits (10.1 vs. 13.0 visits per 100,000 habitants/week; p < 0.001), but this reduction was greater in women than in men (30% vs. 15%; p < 0.001). This reduction was associated with age among women (27%, 31%, and 36% for < 50 years, between 50 and 69 years and > 70 years, respectively, p for age-related trend = 0.041), but not among men. ConclusionsIn this population-level study of Curitiba, Brazil, the reduction in ED visits during the COVID-19 pandemic was greater in women than in men, particularly among those > 70 years of age, suggesting that the sex- and age-related disparities in health care delivery for ACS may have worsened during the COVID-19 pandemic.

The Influence of Socio-demographic Factors and Hospital type on Islamic Work Ethics of Healthcare Providers at Emergency Departments in Jordan

Purpose: Islamic work ethics (IWE) has been an area of attraction for scholars exploring Muslim employees’ attitudes and behaviors. This study aims to examine the IWE of healthcare providers (HCPs) in Jordan’s public and private emergency departments, and test the influence of socio-demographic factors and hospital type on IWE. Methodology: A descriptive cross-sectional study was used. Data were collected from the HCPs in Jordan middle district hospitals using a selfadministered questionnaire. In total, 297 questionnaires were completed and returned for analysis. Descriptive statistics, regression analysis, and independent sample t-test were used to analyze the data. Findings: The HCPs in private EDs showed a higher commitment to IWE than public EDs HCPs, and statistical differences were found between the public and private EDs. Multiple linear regression analysis showed that socio-demographic factors (age, gender, income level, professional classification, and social status) do not significantly influence IWE. Only the hospital type has a significant negative influence on IWE. Conclusion: HCPs in private EDs showed a high level of commitment to IWE than public HCPs. Statistical differences were discovered between the public and private EDs. The regression analysis showed no effect of socio-demographic factors on the IWE. Originality/Significance: This is perhaps the first paper investigating the influence of socio-demographic factors and hospital type on IWE of HCPs at EDs in Jordan. Research Limitations/Implications: This paper was limited to HCPs working in eleven hospitals in Jordan’s middle district. The study’s findings were based on the respondents’ honesty and truthfulness when taking the questionnaire. Implications for research have also been discussed.

Job satisfaction in emergency departments: a comparative study of public and private hospitals

Background/Aims Evaluating job satisfaction levels among healthcare staff can inform decision making for managers. Various factors can affect job satisfaction. This study investigated and compared job satisfaction among healthcare staff working in private and public emergency departments in Jordan. Methods A self-administered questionnaire was distributed to 475 staff members, of which 286 were returned and analysed (50% from private hospitals). Descriptive analysis, independent sample t-tests and multiple regression analysis were used to compare the results based on hospital type and participant characteristics. Results Staff working in public emergency departments had significantly lower levels of job satisfaction than those working in private emergency departments (P&lt;0.001). The lowest scoring domain across both groups was promotion and compensation. Doctors were more likely to have low job satisfaction than staff in other job roles. Conclusions Assessing job satisfaction is important for ensuring staff wellbeing and retention. Further research is needed to understand why staff in public hospitals have lower levels of job satisfaction and what could be done to address this.

Identifying symptoms/illnesses and situations that predispose outpatients to use antibiotics in two healthcare systems

Background: Taking antibiotics outside the guidance of a clinician (nonprescription use) is a potential safety issue and runs counter to antibiotic stewardship efforts. We identified the symptoms and illnesses and situations that may predispose patients to take antibiotics, and we compared these findings between patients attending public primary care clinics and private emergency departments. Methods: A cross-sectional survey was conducted between January 2020 and March 2021 in 6 primary care clinics and 2 emergency departments in the United States. We queried patients about 5 symptoms and illnesses (Fig. 1) and 14 situations (Fig. 2) to investigate whether these would lead the patients to take antibiotics without a prescription. We used the χ2 test to compare the symptoms and illnesses and situations between the respondents from public and private healthcare systems. We set the P value for significance at &lt;.025. Results: In total, the survey had 564 respondents (median age, 49.7 years; range, 19–92), and 72% were female. Most respondents identified as either Hispanic or Latina/Latino (46.6%) or African American or Black (33%), followed by White (15.8%), and other (4.6%). Most respondents had visited public clinics (72%). The most common insurance status for our respondents included Medicaid or county financial assistance program (56.6%), followed by private insurance or Medicare (36.7%) and self-pay (6.7%). In public primary care clinics, only 23% had private insurance or Medicare compared to 72.9% in private emergency departments. Of those surveyed, 69% agreed that antibiotics would improve the recovery from sinus infections, followed by bronchitis (64%), sore throat (64%), cold/flu (61.4%), and diarrhea (31.5%). The proportions of respondents who believed that antibiotics would improve the recovery from diarrhea (36.2% vs 19.4%; P = .004) and sore throat (59.9% vs 48.4%; P &lt; .001) were significantly higher among public versus private outpatient respondents. We did not find significant differences for cold/flu, sinus infection, or bronchitis between these 2 healthcare systems (Fig. 1). In 11 of the 14 situations, patients in public clinics were more likely to report a likelihood of using nonprescription antibiotics than the patients visiting the private emergency rooms (Fig. 2). Conclusions: Future stewardship interventions should be aware of the symptoms and illnesses and situations that may influence outpatients to take nonprescription antibiotics. Addressing modifiable factors (eg, leftover antibiotics, antibiotics given by friends or family, and antibiotics available without a prescription in stores or markets) may also curtail these unsafe practices and reduce antibiotic resistance.Funding: NoneDisclosures: None

Utilising a nurse navigator model of care to improve prisoner health care and reduce prisoner presentations to a tertiary emergency department

BackgroundPrisoners are a vulnerable population requiring complex care interventions in challenging environments, particularly around provision of emergency care. The aim of this study was to explore the effectiveness of a Nurse Navigator (NN) -led prisoner intervention from the perspective of the emergency department. MethodsThis study undertook a retrospective analysis of the prisoner presentations to a public emergency department. It used time-series analysis of publicly available deidentified data, collected during standard care evaluation, to explore the impact of this unique care model over 24 months (12-pre and 12-post). Synthesis of documents pertaining to this NN model of care provide a summary of key initiatives and interventions. ResultsWith the introduction of NN, the rate of change of yearly prisoner presentations dropped from + 32.8% to − 2.7%. Interrupted time-series analysis on emergency department presentations per 1000 prisoners in custody confirmed a postintervention level drop of 15.1% (rate ratio 0.849; 95% CI 0.755–0.954) followed by a period of downward trending of presentations resulting in an absolute drop of 31.5% in twelve months (rate ratio 0.685; 95% CI 0.556–0.843). ConclusionsThe bundle of capacity-building initiatives instigated by the NN appear to have contributed to a reduction of prisoner presentations.

Management of acute low back pain in emergency departments in São Paulo, Brazil: a descriptive, cross-sectional analysis of baseline data from a prospective cohort study

ObjectiveTo describe management strategies used in public emergency departments in a middle-income country for patients with acute non-specific low back pain.DesignA descriptive, cross-sectional analysis of baseline data from a prospective...

Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan.

Violence against health care workers has been widely reported in Pakistan. This study, from September 2019 to April 2020, aimed to determine the effect of low-cost interventions to reduce violent events in two tertiary-care emergency departments in Karachi and Peshawar, Pakistan. In phase one, a surveillance system was established in each department and information on violent events was recorded for three months. In phase two, low-cost interventions designed to reduce violent events were introduced, e.g. awareness-raising material on violence for patients, training for health care workers and visitor identification cards. Violent events were then recorded for another three months and the percentage difference in number of violent events was calculated. In Karachi, 256 violent events occurred before the intervention and 225 after the intervention, a 12.1% reduction. Physical violence events decreased significantly by 42.9% (P = 0.044). The number of events perpetrated by health care workers decreased by 61.9% (P = 0.016) while those perpetrated by patients decreased only by 5.7% (P = 0.538). In Peshawar, 90 violent events occurred before the intervention and 45 events after, a 50.0% reduction (P = 0.009). The number of events perpetrated by health care workers was the same in both phases. Events perpetrated by patients or their companions decreased significantly by 59.72% (P = 0.001). Violence against health care workers can be reduced significantly by improving their prevention and de-escalation skills. Client educational interventions, supplemented with hospital regulations and patient guidance, can also help reduce the incidence of violent events.

Epidemiology and treatment of sepsis at a public pediatric emergency department.

ABSTRACTObjective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital.Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated.Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%.Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Prediction models for severe manifestations and mortality due to COVID‐19: A systematic review

AbstractBackgroundThroughout 2020, the coronavirus disease 2019 (COVID‐19) has become a threat to public health on national and global level. There has been an immediate need for research to understand the clinical signs and symptoms of COVID‐19 that can help predict deterioration including mechanical ventilation, organ support, and death. Studies thus far have addressed the epidemiology of the disease, common presentations, and susceptibility to acquisition and transmission of the virus; however, an accurate prognostic model for severe manifestations of COVID‐19 is still needed because of the limited healthcare resources available.ObjectiveThis systematic review aims to evaluate published reports of prediction models for severe illnesses caused COVID‐19.MethodsSearches were developed by the primary author and a medical librarian using an iterative process of gathering and evaluating terms. Comprehensive strategies, including both index and keyword methods, were devised for PubMed and EMBASE. The data of confirmed COVID‐19 patients from randomized control studies, cohort studies, and case–control studies published between January 2020 and May 2021 were retrieved. Studies were independently assessed for risk of bias and applicability using the Prediction Model Risk Of Bias Assessment Tool (PROBAST). We collected study type, setting, sample size, type of validation, and outcome including intubation, ventilation, any other type of organ support, or death. The combination of the prediction model, scoring system, performance of predictive models, and geographic locations were summarized.ResultsA primary review found 445 articles relevant based on title and abstract. After further review, 366 were excluded based on the defined inclusion and exclusion criteria. Seventy‐nine articles were included in the qualitative analysis. Inter observer agreement on inclusion 0.84 (95%CI 0.78–0.89). When the PROBAST tool was applied, 70 of the 79 articles were identified to have high or unclear risk of bias, or high or unclear concern for applicability. Nine studies reported prediction models that were rated as low risk of bias and low concerns for applicability.ConclusionSeveral prognostic models for COVID‐19 were identified, with varying clinical score performance. Nine studies that had a low risk of bias and low concern for applicability, one from a general public population and hospital setting. The most promising and well‐validated scores include Clift et al.,15 and Knight et al.,18 which seem to have accurate prediction models that clinicians can use in the public health and emergency department setting.

Why patients attend after-hours medical services: a cross-sectional survey of patients across the Australian Capital Territory.

Almost half of Australian after-hours emergency department (ED) presentations are rated as 'non-urgent' by clinicians and are suggested to be managed by community-based services, such as general practice (GP). This paper reports patient reasons for presenting for medical care after hours, and reasons for selection of specific services across a health system. A cross-sectional survey was conducted across the Australian Capital Territory. Patients voluntarily completed questionnaires in waiting rooms during the after-hours periods of one weekday and one weekend in 2019 at 28/51 extended hours GPs, 3/3 medical deputising services (MDS), 3/3 nurse-led walk-in-clinics (WICs), and 2/2 public emergency departments (EDs). Of 3371 presentations, 1992 patients completed a survey, with 58% from GPs (n =1149), 16% from WIC (n =317), 10% from MDS (n =193), and 17% from EDs (n =333). Most patients presented with self-rated new issues (n =987, 49.5%) and were uncertain of the urgency of their issues (n =723, 36.7%). Common reasons for presenting to WIC, MDS, and EDs included the problem occurring after hours, and patients concern about the issue. Common reasons for presenting to GP were related to personal preference for after-hours care. Patients present to after-hours medical services for both perceived need and convenience. Most patients appear to be self-selecting after-hours services appropriately aligned with advertised services; except for GP patients who were attending after hours for care that is often non-urgent and could be seen in usual working hours. This study should be replicated to account for local health systems, and coronavirus disease 2019 (COVID-19)-related changes to health care.

A qualitative study of hospital clinical staff perceptions of their interactions with healthcare middle managers

PurposeThe authors explored clinical staff perceptions of their interactions with middle management and their experiences of the uncongeniality of their working environment.Design/methodology/approachSemi-structured interviews of clinical staff from an Australian public health service's Emergency, Surgery and Psychiatry departments. Volunteer interview transcripts were inductively coded using a reflexive thematic content analysis.FindingsOf 73 interviews, 66 participants discussed their interactions with management. Most clinicians considered their interactions with middle management to be negative based on a violation of their expectations of support in the workplace. Collectively, these interactions formed the basis of clinical staff perceptions of management's lack of capacity and fit for the needs of staff to perform their roles.Practical implicationsStrategies to improve management's fit with clinicians' needs may be beneficial for reducing uncongenial workplaces for healthcare staff and enhanced patient care.Originality/valueThis article is among the few papers that discuss interactions with management from the perspective of clinical staff in healthcare. How these perspectives inform the perception of workplace uncongeniality for clinicians contributes greater understanding of the factors contributing to adversarial relationships between clinicians and managers.

210 Assessment of Emergency Department Health Care Providers’ Readiness for Intimate Partner Violence Screening and Correlation With Cultural Competence

Intimate partner violence (IPV) is a serious public health issue and emergency departments (ED) are often a victim’s only contact with healthcare providers (HCPs). The ED also increasingly serves as a primary source of care for racial/ethnic minorities and other historically marginalized groups because of rising healthcare costs and declining access to care. The need for culturally competent providers, resources, and messaging when addressing IPV cannot be overstated. To inform more inclusive IPV screening strategies, this study explored the intersectionality of IPV readiness and cultural competence among ED HCPs.

74 Trends Of Diabetic Ketoacidosis During COVID-19 Pandemic In Large Urban Public Emergency Department

Diabetic ketoacidosis (DKA) is a common and serious endocrine emergency. Common triggers for diabetic ketoacidosis include infection, cardiovascular events, drug use, medication non-adherence, and new onset diabetes. Early evidence suggests a correlation between COVID-19 infection and DKA. Based on the limited data, it is unclear at this time if increases in DKA are triggered by acute COVID-19 infection, or secondary factors from the pandemic such as lack of access to care or acute stress. In this study, we examine trends in DKA prevalence among patients at an underserved urban public ED within the context of the COVID-19 pandemic.

Associations between floods and bacillary dysentery cases in main urban areas of Chongqing, China, 2005\u20132016: a retrospective study

BackgroundUnderstanding the association between floods and bacillary dysentery (BD) incidence is necessary for us to assess the health risk of extreme weather events. This study aims at exploring the association between floods and daily bacillary dysentery cases in main urban areas of Chongqing between 2005 and 2016 as well as evaluating the attributable risk from floods.MethodsThe association between floods and daily bacillary dysentery cases was evaluated by using distributed lag non-linear model, controlling for meteorological factors, long-term trend, seasonality, and day of week. The fraction and number of bacillary dysentery cases attributable to floods was calculated. Subgroup analyses were conducted to explore the association across age, gender, and occupation.ResultsAfter controlling the impact of temperature, precipitation, relative humidity, long-term trend, and seasonality, a significant lag effect of floods on bacillary dysentery cases was found at 0-day, 3-day, and 4-day lag, and the cumulative relative risk (CRR) over a 7-lag day period was 1.393 (95%CI 1.216–1.596). Male had higher risk than female. People under 5 years old and people aged 15–64 years old had significantly higher risk. Students, workers, and children had significantly higher risk. During the study period, based on 7-lag days, the attributable fraction of bacillary dysentery cases due to floods was 1.10% and the attributable number was 497 persons.ConclusionsThis study confirms that floods can increase the risk of bacillary dysentery incidence in main urban areas of Chongqing within an accurate time scale, the risk of bacillary dysentery caused by floods is still serious. The key population includes male, people under 5 years old, students, workers, and children. Considering the lag effect of floods on bacillary dysentery, the government and public health emergency departments should advance to the emergency health response in order to minimize the potential risk of floods on public.

Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level.

The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury. We included all patients presenting to public emergency departments in South Australia between June 2011-Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia. 372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia. Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.

Epidemiology of maxillofacial soft tissue injuries in an oral emergency department in Beijing: A two-year retrospective study.

Maxillofacial soft tissue injuries (STIs) may differ in epidemiological characteristics from other maxillofacial injuries. The aim of this study was to investigate the epidemiology of maxillofacial STIs in a public oral emergency department in Beijing, China, from 2017 to 2018. In this retrospective study, 5949 patients with maxillofacial STIs and complete medical records were evaluated. Gender, age, etiology, visit date and time, interval between accident and treatment, anatomic injury site, treatment modality, and the number of associated maxillofacial bone fractures or tooth injuries were analyzed. There were 3831 males and 2118 females (ratio 1.81:1). Patients younger than 10years were the most frequently seen group (44.2%). Among adults, 20- to 29-years-old (16.2%) was the most prominent age group. The month of May (11.8%) had the highest incidence of maxillofacial STIs, and February (4.5%) had the lowest incidence. The average number of daily visits was significantly higher on holidays than on workdays. Of the 5949 patients, 45.9% attended at night, 2021 patients had dental trauma, and 31 had jaw fractures. The lips were the most common site of STIs, followed by the chin and gingiva. Lip and gingival STIs were more common in the 0- to 10-years-old group. Chin STIs were more common in the 20- to 39-years-old group. A fall was the leading cause of injury, especially in patients younger than 10years and older than 70years. Approximately 56.7% of the falls resulted in injuries to the lower one-third of the face. Sports injuries were more common among 10- to 29-years-old individuals. STIs of the maxillofacial region were most likely to occur at night, in May and during holidays. Males, children younger than 10years and 20- to 29-years-old adults were high-risk populations. Most maxillofacial STIs involved the lips, and one-third of the patients had dental trauma.

Thoughts on Personnel Management of Disease Control Departments after Public Health Emergencies Based on the Perspective of Human Resource Management

In COVID-19 outbreak, such a sudden public health incident, the deficiency of China’s department of CDC exposed, especially the disease control department’s ability to cope with risk is low. For public health emergency department personnel management, it is a wake-up call for disease control. Starting from the current situation of personnel management in the disease control department, from the perspective of human resources management, this paper discusses how to improve the management of personnel to improve the capacity of the disease control department to respond to public health emergencies, and puts forward relevant suggestions and measures.

How Do Data Bolster Pandemic Preparedness and Response? How Do We Improve Data and Systems to Be Better Prepared?

How are data driving the response for the ongoing COVID-19 pandemic? How do data support preparedness toward epidemics and pandemics? How do data inform the potential severity and spread of an outbreak? Past infectious disease outbreaks have demonstrated several challenges associated with rapid aggregation, integration, and sharing of data to inform a response during an outbreak. The ongoing pandemic response has demonstrated the value of timely data collection and sharing and the usage of data for decision-making.

Factors that predict the perception of spirituality and spiritual care of nurses working in high-risk units and the effect of death anxiety.

Spirituality contributes to the health and well-being of individuals. This study investigates the factors that predict the spirituality perceptions and the effect of death anxiety of nurses. This was a cross-sectional study, 382 nurses working in four public hospitals intensive care and emergency departments setting in two different cities in Turkey. Variables predicting the total and subscale scores of the Spirituality and Spiritual Care Rating Scale of nurses were determined by linear multiple regression analysis. Except for the religiousness subscale, the satisfaction level of nurses was found to be a significant predictor in total of Spirituality and Spiritual Care Scale. Nurses working in high-risk units are unclear about their perception of spirituality and spiritual care.

Predicting waiting time to treatment for emergency department patients

BackgroundThe current systems of reporting waiting time to patients in public emergency departments (EDs) has largely relied on rolling average or median estimators which have limited accuracy. This study proposes to use machine learning (ML) algorithms that significantly improve waiting time forecasts. MethodsBy implementing ML algorithms and using a large set of queueing and service flow variables, we provide evidence of the improvement in waiting time predictions for low acuity ED patients assigned to the waiting room. In addition to the mean squared prediction error (MSPE) and mean absolute prediction error (MAPE), we advocate to use the percentage of underpredicted observations. The use of ML algorithms is motivated by their advantages in exploring data connections in flexible ways, identifying relevant predictors, and preventing overfitting of the data. We also use quantile regression to generate time forecasts which may better address the patient’s asymmetric perception of underpredicted and overpredicted ED waiting times. ResultsUsing queueing and service flow variables together with information on diurnal fluctuations, ML models outperform the best rolling average by over 20 % with respect to MSPE and quantile regression reduces the number of patients with large underpredicted waiting times by 42 %. ConclusionWe find robust evidence that the proposed estimators generate more accurate ED waiting time predictions than the rolling average. We also show that to increase the predictive accuracy further, a hospital ED may decide to provide predictions to patients registered only during the daytime when the ED operates at full capacity, thus translating to more predictive service rates and the demand for treatments.