Spoke Network Research Articles

DEVELOPMENT OF A HUB–SPOKE NETWORK FOR TRANSCATHTER AORTIC VALVE IMPLANTATION: THE INTERVENTIONAL CARDIOLOGY UNIT OF IRCCS SAN RAFFAELE HOSPITAL (OSR HUB–SPOKE)

Abstract Background The growing prevalence of aortic stenosis determined in recent years an increase in candidates for percutaneous aortic valve replacement (TAVI), bringing out a difficult access to this procedure. In order to reduce waiting lists and to guarantee the training of the Interventional Cardiologists of Centers not equipped with on–site cardiac surgery, we implemented a TAVI protocol with one Hub center, the Interventional Cardiology Unit of IRCCS San Raffaele Scientific Institute, Milan, and two participating Spoke Centers: the ASST–Franciacorta Chiari Center and Valduce Hospital, Como.The aim of this study is to report in hospital outcomes of patients treated using this model of Hub–Spoke Network. Methods Patients included in this model were selected in the Spoke center where baseline clinical evaluation with echocardiography and CT scan were performed (inclusion and exclusion criteria attached). The cases were then discussed with a multidisciplinary team on–line and the procedure planned (access, valve type size). Once the procedure was scheduled, the patients underwent a single day transport to the Hub Center where they underwent TAVI and a same day return to the Spoke Center. A bailout hospitalization in the Hub Center was available in case of major complication. All Spoke Centers patients who underwent TAVI procedures in our Center according to our protocol were included in this analysis. The primary study objective was in hospital major adverse cardiac events (all cause or cardiovascular mortality, stroke, myocardial infarction); secondary study objectives were technical success, prolonged recovery in Hub Center and major vascular complications. Results Since 2019, a total of 69 patients underwent TAVI with the Hub and Spoke model. Mean age was 83 years ± 6 and mean ejection fraction was 59% ± 7%. Two patients (2.9%) had a prolonged hospitalization in the Hub center for a major vascular complication and an intra–procedural cardiac arrest, successfully resuscitated. Technical success was reached in 97.1% of patients. One patient experimented an ischemic stroke after the return in the spoke center: in hospital MACE was than 1.4%. Conclusion Considering the growing prevalence of aortic stenosis, The Hub Spoke Model for TAVI guarantees reduction in waiting lists, "access to care" for patients referred to Spoke centers, involvement and improvement of skills of their Interventional Cardiologists, keeping a high level of safety and efficacy.

A hub and spoke model to supply the Sicilian neurorehabilitation demand: effects on hospitalization rates and patient mobility.

Cerebrovascular diseases in Sicily have led to high mortality and healthcare challenges, with a notable gap between healthcare demand and supply. The mobility of patients seeking care, both within and outside Sicily, has economic and organizational impacts on the healthcare system. The Hub and Spoke model implemented by the IRCCS Centro Neurolesi "Bonino-Pulejo" of Messina aims to distribute advanced neurorehabilitation services throughout Sicily, potentially reducing health mobility and improving service accessibility. The evaluation was based on calculating hospitalization rates, examining patient mobility across Sicilian provinces, and assessing the financial implications of neurorehabilitation admissions. Data from 2016 to 2018, covering the period before and after the implementation of the Hub and Spoke network, were analyzed to understand the changes brought about by this model. The analysis revealed a significant increase in hospitalization rates for neurorehabilitation in the Sicilian provinces where spokes were established. This increase coincided with a marked decrease in interregional health mobility, indicating that patients were able to receive high-quality care closer to their residences. Furthermore, there was a decrease in both intra-regional and inter-regional escape rates in provinces within the Hub and Spoke network, demonstrating the network's efficacy in improving accessibility and quality of healthcare services. The implementation of the Hub and Spoke network substantially improved neurorehabilitation healthcare in Sicily, enhancing both accessibility and quality of care for patients. The network's establishment led to a more efficient utilization of healthcare resources and balanced distribution of services. These advancements are vital steps toward equitable and effective healthcare delivery in Sicily.

Abstract WP65: Impact of Artificial Intelligence on Acute Ischemic Stroke Treatment in a Large Academic Healthcare System

Introduction: We aimed to evaluate the impact of the implementation of a stroke triage artificial intelligence (AI) software on a large academic healthcare system. Methods: A retrospective study was conducted in our spoke and hub network comparing equal corresponding periods of pre- and post- Viz.ai implementation between January 2021 and December 2022. Door to needle, door to puncture (DTP), successful reperfusion rates, transfer rates, and clinical outcomes at discharge were compared. Results: The analysis encompassed a total of 5,456 patients including 2313 pre- and 2275 post-Viz.ai patients across 11 spokes and 416 pre- and 452 post-Viz.ai patients across 4 hubs. Among 868 patients undergoing EVT at the 4 hubs, there was no differences in baseline data except for a higher baseline NIHSS score in the post Viz.ai group. We found an overall absolute reduction of transfers by 60 cases equating to a statistically significant decrease of 2.3% (P=0.04). The results showed an overall decrease by 13.5 minutes (8.1%) which was not statistically significant (P=0.3). There was an overall statistically significant decrease of 6 minutes (9.5%) in DTP times from 63 (23-98) minutes to 57 (23-79) minutes (P=0.01). No other differences in outcomes were noted between both groups. Conclusion: The automatic AI software was able to show a notable impact in our hub and spoke mature network driven by decrease of unnecessary transfers, DIDO and DTP. These data support the role of AI software as an effective triaging tool in the stroke and hub networks. More studies are needed to confirm these results.

Treating and caring for migrant populations suffering from infectious diseases: the experience of the hub&spoke network set up by the Civico Benfratelli ARNAS Hospital in Palermo (Sicily Region, Southern Italy)

This paper describes the experience carried out in a general hospital, implemented in collaboration with a city network of associations involved in the care of migrant populations. Considering the vulnerability of these populations, the difficulty of access to healthcare facilities, and the linguistic and cultural barriers, an organisational model was designed characterised by the concentration of highly complex care (hub centre) supported by a network of peripheral reception centres (spoke centres) responsible for selecting patients and sending them to the centre of reference with the aim of offering screening for sexually transmitted infections, tuberculosis, taking charge of pathologies, including non-infectious ones, treatment, and follow-up. The effectiveness of the model was measured in relation to the continuum of care and its effectiveness with reference to the Joint Commission International guidelines.

Abstract WP63: Direct Physician Call to Spoke Reduces Door to Needle Time in a Telestroke Network

Background: Door-to-needle time (DTN) and strategies to reduce DTN are well published, but less is known about specific processes that may contribute to DTN in sites using telestroke. We aimed to reduce potential delays in connecting the telestroke physician with the spoke by eliminating the initial call by telestroke physicians to the call center. Methods: A retrospective analysis examined telestroke patients treated with IV thrombolysis from 06/01/2018 to 03/15/2023 in a 20 spoke network. Telestroke physicians began calling the spoke back directly (instead of calling transfer center to be connected) in July 2022. We compared data and outcomes in the two groups; Prior to Direct Phone (PDP) and After Direct Phone (ADP). Primary outcome analyzed DTN before and after direct connection. Secondary outcome was telestroke page to video times. Primary and secondary outcomes were analyzed using quantile regressions specifying the median, adjusted for confounding variables determined in preliminary analyses. A subgroup analysis was completed in patients transferred for endovascular thrombectomy (EVT) after IVT, to evaluate Door in Door out time (DIDO), using a median regression adjusted for potential confounding variables. Results: There were 580 patients in this study; 469 patients in the PDP group and 111 patients in the ADP group. Patients had a mean age and SD of 69.13 ±15.03 years and a median NIHSS (interquartile range) of 6 (4, 12). After adjusting for potential confounding variables, DTN in the ADP group was 9.22 minutes quicker than in the PDP group, [95% Confidence (CI), 2.07 - 16.36], p = 0.01. Adjusted telestroke page to video times were 2.60 minutes quicker in the ADP compared to the PDP group, [95%CI, 0.01 - 5.20], p = 0.05. There were 137 patients (121 in PDP; 24 in ADP) in the subgroup analysis. There were similar DIDO times in both groups; 1.06 minutes faster in the ADP group, but not statistically significant [95%CI, -14.56, 16.68], p = 0.89. Conclusion: Eliminating one step in the telestroke process by connecting directly to the telestroke site resulted in faster treatment times. Removing the call center from the initial phone call did not delay DIDO times but the downstream effect from removing the step was likely minimized in patients transferred for EVT.

Optimizing Dry Port Locations Using Hub And Spoke Network Design - A Conceptual Framework For Inland Water Ports In Assam

Optimizing Dry Port Locations Using Hub And Spoke Network Design - A Conceptual Framework For Inland Water Ports In Assam

Heuristic methods for integrated incremental schedule design and fleet assignment problem for hub and spoke network

Heuristic methods for integrated incremental schedule design and fleet assignment problem for hub and spoke network

Optimization of Two Stage Intra-City Express Hub Location Based on Hybrid Hub and Spoke Network

Optimization of Two Stage Intra-City Express Hub Location Based on Hybrid Hub and Spoke Network

Heuristic methods for integrated incremental schedule design and fleet assignment problem for hub and spoke network

Heuristic methods for integrated incremental schedule design and fleet assignment problem for hub and spoke network

Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina

IntroductionThe incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. MethodsThe clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. ResultsBoth spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. ConclusionComparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.

The Economics of Ransomware Attacks on Integrated Supply Chain Networks

We explore the economics of ransomware on production supply chains. Integrated supply chains result in a mutual-dependence between firms that can be exploited by cyber-criminals. For instance, we show that by targeting one firm in the network the criminals can potentially hold multiple firms to ransom. Overlapping security systems may also allow the criminals to strike at weak points in the network. For instance, it may be optimal for the attacker to target a supplier in order to ransom a large producer at the heart of the production network. We introduce a game theoretic model of an attack on a supply chain and solve for two types of Nash equilibria. We then study a hub and spoke example before providing simulation results for a general case. We find that the total ransom the criminals can demand is increasing in the average path length of the network. Thus, the ransom is lowest for a hub and spoke network and highest for a line network. Mitigation strategies are discussed.

The International Society for Biological and Environmental Repositories Presents Abstracts from Its Annual Meeting

The International Society for Biological and Environmental Repositories Presents Abstracts from Its Annual Meeting

Toward social-health integration in Sicily: description of the first hub and spoke model to improve the diagnostic therapeutic care paths for neurorehabilitation.

The study describes a hub and spoke network for neuro-rehabilitation recently activated in Sicily, and evaluates the before-after changes yielded, in terms of integrated care. A set of indicators based on data contained in the administrative database of inpatients of the Regional Health System are presented and discussed. Statistical analysis was conducted both globally and separately for the 9 Sicilian provinces (Agrigento, Caltanissetta, Catania, Enna, Messina, Palermo, Siracusa, Ragusa, and Trapani). Results showed an increase in admissions of people residing in the province where the Spokes have been opened: Trapani (+32.4%), Messina (+7.8%) and Palermo (+4.4%); besides a significant increase of patients from healthcare facilities proportion (p = 0.001) and from acute wards (p = 0.029). In addition, we found a decrease of discharge to protected healthcare facilities (p = 0.001) and to acute wards (p < 0.001), as well as an increase of discharges to home (p = 0.018). In conclusion, it would seem that the activation of this network has facilitated the management of these patients, avoiding unnecessary migrations to other provinces and/or regions, and improving the regional care service for neuro-rehabilitation. Future research will be direct to investigate this aspect, focusing on before-after variations in hospitalization rates and origin- destination patient flows.

Is China's international trade exacerbating urban environmental pollution?——A quasi-natural experiment based on the opening of the CHINA RAILWAY Express

The level of international trade liberalization and facilitation between Chinese cities and countries along the route has increased significantly since the opening of the CHINA RAILWAY Express. Increased economic activity is bound to significantly affect environmental quality. However, academic empirical evidence on the effect of international trade on environmental quality is inconsistent. Moreover, there is need to further clarify the specific effect paths. Based on data from various cities in China, this study examines the direction and potential effect mechanisms of China's international trade activities on the environmental status represented by carbon dioxide using the Staggered Differences-in-Differences method, considering the opening of the CHINA RAILWAY Express as an entry point. The opening of the CHINA RAILWAY Express promotes environmental pollution in Chinese cities; this finding still holds after a series of placebo and robustness tests. A study of the mechanism of influence between the two suggests that the opening of the CHINA RAILWAY Express increased environmental pollution at the city level in China by promoting industrial agglomeration and improving green technology innovation. A study based on regional heterogeneity showed that the opening of the CHINA RAILWAY Express insignificantly negatively affected environmental quality in eastern China but significantly increased environmental pollution in the central and western regions. Further examination of the spoke network effect of the environmental pollution effect of the CHINA RAILWAY Express revealed that the opening of the CHINA RAILWAY Express in one city significantly negatively affected the environmental quality of all cities within a distance of 200 km. Although the CHINA RAILWAY Express reduces the environmental quality of cities in China where they are opened, studies using data from 145 countries or regions worldwide show that access to the CHINA RAILWAY Express is beneficial for the improvement of environmental quality in countries and regions along the route. This study explores the environmental effects of international trade from the perspective of the CHINA RAILWAY Express, enriches the relevant studies on the relationship between the two, and proposes new perspectives and conclusions to provide new empirical evidence and policy recommendations in the context of China's planning to build a strong trade nation and accelerate the transition to a low-carbon economy.

Abstract TP45: Demonstration Of High Diagnostic Accuracy Of Cerebral Ischemia In A Large Academic Hub And Spoke Telestroke Network

Introduction: Telestroke facilitates emergent assessment of patients with suspected acute ischemic stroke (AIS) to identify candidates for acute interventions. The diagnostic accuracy of the telestroke consultation of a large academic hub and spoke telemedicine network has yet to be investigated. The goal of our study is to determine the diagnostic accuracy of the initial telestroke consultation. Methods: This is an IRB-exempt retrospective study including all patients evaluated for cerebral ischemia via video telestroke consultation in a large academic hub and spoke telemedicine network from 2019 to 2020. Detailed chart review was conducted to identify initial suspected diagnosis and final diagnosis. Cerebral ischemia was defined as AIS and transient ischemic attack (TIA). All other diagnoses were defined as stroke mimics. Data was organized into continuous and categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, area under the curve (AUC) and likelihood ratio (LR+) for the initial telestroke consultation diagnosis were calculated while using the final diagnosis as the gold standard diagnosis. Results: A total of 1043 patients met inclusion criteria. Final diagnosis of cerebral ischemia was made in 63.5% of all patients (539/1043 with AIS,123/1043 with TIA). Stroke mimic was diagnosed in 36.5% patients (381/1043). The sensitivity and specificity of telestroke evaluation for diagnosis of cerebral ischemia were 97.1% and 81.4%, respectively. PPV was 90.1%, and NPV was 94.2%. Overall diagnostic accuracy was 91.4% with a LR+ of 5.21 and AUC of 0.89. The most common stroke mimics were metabolic encephalopathy (13.7%, 52/381), migraine (10.8%, 41/381) and seizure (10.5%, 40/381). Conclusions: This study highlights the high diagnostic accuracy of telestroke providers to diagnose cerebral ischemia and stroke mimic in a large academic hub and spoke network. Further research is needed to investigate methods to improve our diagnostic accuracy further, as well as explore the application of tele-neurology in the non-stroke setting.

Inter-hospital cardiorespiratory telemonitoring of newborns and infants: a wellworking example of a hub and spoke network

BackgroundPatients who experience cardiorespiratory events usually have to be moved to specialized centers to perform cardiorespiratory studies. To avoid the transfer of these patients to specialized centers, a network has been created based on an interchange system, where the recordings were uploaded in unspecialized centers (spokes) and downloaded by the Sleep Disorders Breathing (SDB) Center (hub) to be analyzed.MethodsThe inter-hospital network was established in November 2008. Initially only 3 non-tertiary hospitals in the Tuscany Region joined the network. Currently, 12 Tuscany hospitals are included.ResultsFrom November 2008 to December 2020, 625 recordings were collected belonging to 422 infants.No recurrent life-threatening episode or infant death occurred in the study population and none of the infants needed to be readmitted or be moved to a tertiary center, except infants who underwent home monitoring.The discharge diagnoses belong to the following categories: apnoea, respiratory problem of the newborn, syncope, gastroesophageal reflux, altered consciousness, transient loss of consciousness and cyanosis.ConclusionsThis study shows that the inter-hospital network is an efficient system that allows accurate and safe management of infants at risk for apnoea, bradycardia, and hypoxemia to remain in unspecialized centers, avoiding unnecessary transfers of patients and over – hospitalizations.

Shared leadership in integrated care networks: the case of “hub and spoke” networks in oral and maxillofacial surgery (OMFS) in the English NHS

PurposeThe purpose of this paper is to explore leadership in the context of the hub and spoke network in oral and maxillofacial surgery (OMFS) in the English National Health Service (NHS).Design/methodology/approachThis paper is a conceptual paper using literature relating to the antecedents of shared leadership and relevant policy documents pertaining to both NHS policy and the development of OMFS. The paper is informed, theoretically by the conceptual lens of shared leadership.FindingsThe paper identifies the challenges that may be faced by policymakers and those involved in the hub and spoke network in developing shared leadership. It also reveals the implications for policymakers in developing shared leadership.Research limitations/implicationsThe paper is conceptual. It is acknowledged that this is a preliminary study and further work will be required to test the conceptual framework empirically. The paper discusses the policy implications of developing leadership in the hub and spoke network. As networks are of interest internationally this has wider relevance to other countries.Originality/valueThere is limited research on the antecedents of shared leadership. In addition, the conceptual framework is applied to a new policy context.

Chronic Non-cancer Pain Management in a Tertiary Pain Clinic Network: a Retrospective Study.

Chronic pain is a distressing condition that should be treated in specialized pain clinics. Pain clinics offer a holistic, evidence-based approach, including pharmacological, complementary, and invasive treatments. This study aimed to provide preliminary information regarding chronic pain treatments and identify reasons for accessing an important hub-spoke pain clinic network. A retrospective multicenter cross-sectional study was carried out. A total of 1606 patients' records were included. Patients were selected from the 26 pain clinics of a single region in Italy. Univariate and multivariate logistic regression models were used. Multivariate models showed that the use of opioids were considered effective for severe or moderate pain [odds ratio (OR) 0.41; 95% 0.33-0.51], while the use of invasive treatments (OR 2.45; 95% 1.95-3.06) and the use of complementary therapy (OR 1.87; 95% 1.38-2.51) were associated with severe or moderate pain. Overall, age, sex, nonsteroidal anti-inflammatory drugs (NSAID) use, a combination of NSAIDs, complementary therapies, and a combination of opioids and invasive treatments did not seem to be significantly associated with the nature of pain. Multivariate models confirmed that clinical parameters such as the nature of pain, multi-diagnosis, more than one site of pain, treatments, and general practitioner, but not the severity of pain and use of invasive treatments, had an impact on the choice of a pain clinic. Opioids are useful in managing moderate or severe chronic pain. Multimodal approaches are used for the management of chronic pain. Moreover, it is not clear how patients are addressed to access different pain clinics (spoke versus hub) networks. More widespread adoption is needed for an interdisciplinary approach to managing chronic pain and adopting guideline recommendations, and rigorous research is required to provide more substantial evidence and support clinical practice.

Development of the Hub and Spoke network model in natural disaster management

Indonesia is a country with high disaster vulnerability. Disasters have a huge impact on a nation’s economic development. According to the National Agency for Disaster Management, a disaster is an event or a series of events that threatens and disrupts the lives and livelihoods of people, caused by either natural factors and/or non-natural factors, as well as human factors and resulting in human casualties to lead. Environmental damage, property damage and psychological impact. This study is limited to hazards caused by natural factors, including nine types of threats, namely: earthquakes, tsunamis, volcanic eruptions, landslides, floods, flash floods, drought, forest and land fires, and extreme waves and abrasion. As an archipelago country, Indonesia has challenges in disaster management. Another thing behind this study is that there is a discrepancy between disaster maps and the location (distribution) of ships that have the potential to be deployed in disaster management, which will affect the duration of the emergency response time and the high cost of disaster management. What’s more, there are conditions in which ships cannot perform certain coping functions, affecting the inability to effectively treat disaster victims, potentially increasing fatalities. Not all ships are suitable for disaster response operations in specific areas, resulting in the emergency response time being too long and the cost of disaster response being high. The purpose of this study is to evaluate the effectiveness of the existing ship distribution state that can be used in disaster management versus the existing disaster map. The research method used is to collect data and identify potential disasters in Indonesia. Then collect data and map the type and number of ships and the distribution of ship bases that can be used in disaster management. Using qualitative analysis, assess the discrepancy between vessel availability and distribution and the potential location and nature of the disaster in Indonesia. The expected result is that there is a match between the availability and distribution of vessels and the potential of the location and nature of the disaster in Indonesia.

Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism.

Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.