Total Patient Time Research Articles

Evaluation of a hub-and-spoke model for the delivery of femtosecond laser-assisted cataract surgery within the context of a large randomised controlled trial

AimsTo test a hypothesis that cataract operating room (OR) productivity can be improved with a femtosecond laser (FL) using a hub-and-spoke model and whether any increase in productivity can offset...

Subcutaneous trastuzumab (Herceptin) versus intravenous trastuzumab for the treatment of patients with HER2-positive breast cancer: A time, motion and cost assessment study in a lean operating day care oncology unit

ObjectiveThe subcutaneous (SC) formulation of trastuzumab represents an alternative to the intravenous (IV) infusion in the treatment of patients with HER2-positive metastatic and early breast cancer. We compared the two formulations in terms of time and cost differential. Study desingWe conducted a time, motion and cost assessment study in a lean operating day care oncology unit to determine and compare the time and costs of trastuzumab SC versus IV administration in patients with HER2-positive breast cancer. Outcomes were the mean costs and the mean dedicated time of the health care professional (HCP) and patient chair time. Direct observation methodology was applied to collect data and statistical analysis was performed. ResultsThe total preparation and administration time for trastuzumab IV was 4.07 times longer than the total time required for the trastuzumab SC administration. The total patient time spent in the day care oncology unit (in minutes) was 71% shorter with using SC administration. IV administration costs € 50.4 ($54,89) more in HCP time and consumable supplies and €162.53 ($177.00) of drug wastage. SC administration was associated with a total time saving of 53.7min for the HCPs and 122.5min for the patients. The administration of trastuzumab SC was translated in a cost saving of €212.93 ($231.73) per patient episode compared to trastuzumab IV, which could lead to a total potential saving of €3,832.74 ($4,171.06) over a full course of treatment (18 cycles) ConclusionSC administration of trastuzumab was associated with a substantial reduction in active HCP time, patient chair time, unit time, and overall cost. These time and cost could be used to increase capacity within existing resources in a lean operating day dare oncology unit.

Time and feasibility of prevention in primary care

Prevention is an essential task in primary care. According to primary care physicians (PCPs),lack of time is one of the principal obstacles to its performance. To assess the feasibility of prevention in terms of time by estimating the time necessary to perform all of the preventive care recommended, separately from the PCPs and patient's perspectives, and to compare them to the amount of time available. A review of the literature identified the prevention procedures recommended in France, the duration of each procedure and its recommended frequency, as well as PCPs' consultation time. A hypothetical patient panel size of 1000 patients, representative of the French population, served as the basis for our calculations of the annual time necessary for prevention for a PCP. The prevention time from the patient's perspective was estimated from data collected from a previous study of a panel of 3556 patients. For PCPs, the annual time necessary for all of the required preventive care was 250 hours, or 20% of their total patient time. For a patient, the annual time required for prevention during encounters with a PCP ranged from 9.7 to 26.4 minutes per year. The mean total encounter time was 75.9 minutes per year. Nearly 73% of patients had a prevention-to-care time ratio exceeding 15%. Feasibility thus differs substantially between patients. These differences correspond especially to disparities in the annual care time used by each patient. Specific solutions should be developed according to the patients' utilization of care.

Case Study of Lean in Hospital Admissions to Inspire Culture Change

The hospital admissions process is a distinct experience for patients as this is where they start their journey for medical care, usually with a mix of anxiety and anticipation about what is to follow. This process also happens to be long and stressful, with numerous steps, frequent delays, and the occasional glitches along the way. In this study, we used lean thinking and discrete-event simulation to map and model the inpatient admissions process at a multi-specialty hospital in order to improve patient flow and reduce unnecessary waiting and handling by patients and staff. We found that by applying a combination of simple but complementary lean techniques, it was possible to reduce the total patient time in the system by up to 43%, without incurring additional costs or using more resources. The potential for achieving substantial improvements at low cost, combined with the approach of validation-prior-to-implementation adopted in this study, can both help process engineers and engineering managers to build support for any proposed lean initiative. This also makes it possible to sustain continuous improvement in the long term, which is at the heart of the lean approach.

Doing more than ACT: The Dutch FACT model, flexible assertive community treatment

Background/objectivesAssertive community treatment (ACT) has become the standard for integrated care for people with severe mental illnesses. Limitations of ACT are the lack of flexibility, the limited feasibility in rural areas, the limited population and the time-unlimited nature. These limitations can be overcome by flexible assertive community treatment (Flexible ACT), developed in the Netherlands and introduced in several European countries.MethodsThree studies were done between 2006 and 2015 on the results of the introduction of Flexible ACT, two in The Netherlands and one in the UK.ResultsThe outcomes in the Netherlands data show the effectiveness of Flexible ACT. Remission of schizophrenia increased form 19% to 31%. Bed use was reduced and quality of life increased. Effectiveness of FACT was also shown in the UK, where total patient time in hospital declined by half, even though the average time service providers spent with patients also declined. Collected data of the digitalized boards show that the board is used in accordance with the FACT model. Transition rate to primary care is 5–10% per year.Discussion/conclusionThe introduction of Flexible ACT has been shown to benefit patients with severe mental illness and indicate the ability of to allocate human resources in mental health care more efficiently. Introduction to other countries will be accompanied by research on the effectiveness and feasibility within other cultures.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Abstract P6-11-06: Time and value of chemotherapy administration burden in a Swedish hospital

Abstract Background Administration of treatment for cancer patients can require substantial health care resources and differences in administration burden between treatments are therefore important to take into account when comparing them. Besides the direct personnel and bed time, the administration can also have broader consequences on the organisation and process of care delivery, as well as on the patients. How to value differences in these parameters is however not straightforward. Nab-paclitaxel and paclitaxel are examples of two treatments with important differences in administration burden, and the objective of this study was to perform a time-motion study to compare time required for treatment administration. Material and methods Breast cancer patients vising the oncology day care unit at the department of oncology at Akademiska Hospital in Uppsala, Sweden, as part of their regular treatment-course with nab-paclitaxel (n=13) or paclitaxel (n=9) were included in the study. Time data collection was based on a questionnaire answered by hospital staff. Time for infusions and the total patient time in hospital were measured for each patient. Results Mean infusion times per administration of nab-paclitaxel and paclitaxel were 42.1 (Standard deviation (SD) 20.7) minutes and 104.3 (SD 43.3) minutes, respectively. Total patient times in clinic per infusion were 82.2 (SD 40.9) minutes and 183.9 (SD 34.8) minutes, respectively. A 12-week treatment course of nab-paclitaxel (every three weeks), nab-paclitaxel (weekly) and paclitaxel (weekly) would require in total 2.8, 8.4 and 20.9 hours of infusion time, respectively. The corresponding patient time in hospital would be 5.5, 16.4 and 36.8 hours, respectively. Conclusion There can be substantial differences in nurse and facility resources required for administration of chemotherapy, our data showed approximately a 7-fold difference in patient, personnel and facility time requirements between the compared treatments. In a time with shortage of both hospital personnel and facilities, the valuation of these resources is not easy and may have broader impact on the organisation and delivery of care. Monetary valuation using rent cost or salaries may in a time of resource shortage underestimate the true opportunity cost, and more research and discussions on how to prioritise use of these resources versus other costs are therefore needed. Citation Format: Nilsson A, Lundkvist J, Lindman H. Time and value of chemotherapy administration burden in a Swedish hospital. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-06.

Annual Patient and Caregiver Burden of Oncology Clinic Visits for Granulocyte-Colony Stimulating Factor (G-CSF) Therapy in the United States (US)

Introduction: Cancer patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drug therapy often have suppressed white blood cell counts and are at risk for febrile neutropenia (FN). Treatment with G-CSFs at least 24 hours after administration of myelosuppressive chemotherapy is indicated for patients with a clinically significant incidence of FN. In the US most doses of G-CSFs are administered in the clinic during separate visits after the chemotherapy session, to ensure on label administration. Patients must return to the clinic, usually the next day, for G-CSF administration, often accompanied by a family member or other informal caregiver. Self-administration in the home is sometimes an option, but can be an unattractive option, due to high pharmacy co-pays, patient discomfort with self-treatment, physician concerns, etc. Therefore, the time and economic burden on patients and informal caregivers of clinic visits for G-CSF injections may be significant, and has not previously been estimated from a societal perspective in the US.Methods: The total national patient and informal caregiver time and cost burden of prophylactic G-CSF clinic (physician office and hospital outpatient) visits was projected for calendar year 2015. Total annual visits for G-CSF injections following myelosuppressive chemotherapy for non-myeloid malignancies were estimated from models using data collected from the oncology literature, cancer patient databases (SEER, Oncology Services Comprehensive Electronic Records (OSCER)), and publically-available G-CSF revenue and pricing data. Average patient and caregiver travel times per visit, plus time in the clinic, were estimated from responses to a questionnaire completed by 598 patients in an ongoing prospective observational study (Prospective Study of the Relationship between Chemotherapy Dose Intensity and Mortality in Early-Stage (I-III) Breast Cancer Patients (CABS)). Total travel time plus time in the clinic for the G-CSF injection were cumulated for both patients and informal caregivers accompanying patients to the clinic. Total travel distance in miles and travel costs were estimated. The opportunity cost of time spent by patients and caregivers in G-CSF visits was monetized using national hourly wage data from the Bureau of Labor Statistics.Results: The estimated total number of clinic visits for G-CSF injections in the United States following myelosuppressive chemotherapy for non-myeloid malignancies is 1.7 million visits for approximately 400,000 patients in 2015. Two-thirds of patients are expected to be accompanied to the visit by an informal caregiver (1.1 million visits). Mean(SD) travel time (round-trip) per visit is estimated at 62(50) minutes; with mean(SD) time in the clinic of 41(68) minutes. Mean(SD) travel distance round-trip is estimated to be 35(28) miles. The total national patient and informal caregiver time commitment for one year for travel to and from the clinic, plus time at the clinic, is estimated at 4.86 million hours (12.1 hours per patient), with their time valued at approximately $87.2 million ($218 per patient). The cumulative annual travel distance for G-CSF clinic visits is estimated at 59.7 million miles, at a total transportation cost of $28.2 million ($70 per patient). The total economic impact of time plus transportation costs is $115 million.Table 12015 Estimated Patient and Caregiver Burden of G-CSF Clinic VisitsClinic VisitsCumulative Time (hours)Cumulative Travel MilesCumulative Time+Travel CostsPatients1,700,0002,921,16759,726,667$72.4 millionCaregivers1,127,1001,936,73439,598,780$43.0 millionTotal1,700,0004,857,90159,726,667$115.4 millionConclusions: The patient and informal caregiver burden of clinic visits for G-CSF therapy following myelosuppressive chemotherapy is a significant addition to the total disease burden borne by patients and their families. Efforts to reduce this burden for the patient and caregiver should be pursued. DisclosuresStephens:Amgen, Inc.: Consultancy; InnoPeritus: Consultancy. Li:Amgen, Inc.: Employment, Equity Ownership. Reiner:Amgen, Inc.: Employment. Sheldon:Amgen, Inc.: Employment. Tzivelekis:Amgen Inc.: Employment, Equity Ownership.

Scribes in an Australian private emergency department: A description of physician productivity.

The study aims to determine if trained scribes in an Australian ED can assist emergency physicians (EPs) to work with increased productivity. This was a pilot, prospective, observational study conducted at a private ED in Melbourne. A scribe is a trained assistant who works with an EP and performs non-clinical tasks that reduce the time spent providing clinical care for patients. Shifts with and without a scribe were compared. The primary outcomes were patients per hour per doctor and billings per patient. Additional analyses included total patient time in ED; individual doctor productivity; time to see a doctor; time on ambulance bypass; and complaints/issues identified with scribes. There was an overall increase in doctor consultations per hour of 0.32 patients (95% confidence interval (CI) 0.17, 0.47). This varied between doctors from an increase in patients per hour of 0.16 (95% CI -0.09, 0.40) to 0.65 (95% CI 0.41, 0.89). Billings per patient were increased (AUD15.24; 95% CI -AUD18.51, AUD48.99), but the increase was not statistically significant; time to see a doctor reduced by 22 min (95% CI 11, 33); bypass episodes reduced by 66 min per shift (95% CI 11, 122), total patient ED stay remained constant. In this pilot study, scribe usage was feasible, and overall improvements in consultations per hour were seen. Overall income improved by AUD104.86 (95% CI AUD38.52, AUD171.21) per scribed hour. Further study is recommended to determine if results are sustained or improved over a longer period.

Improving patient flow at a family health clinic.

This paper presents an analysis of a residency primary care clinic whose majority of patients are underserved. The clinic is operated by the health system for Bexar County and staffed primarily with physicians in a three-year Family Medicine residency program at The University of Texas School of Medicine in San Antonio. The objective of the study was to obtain a better understanding of patient flow through the clinic and to investigate changes to current scheduling rules and operating procedures. Discrete event simulation was used to establish a baseline and to evaluate a variety of scenarios associated with appointment scheduling and managing early and late arrivals. The first steps in developing the model were to map the administrative and diagnostic processes and to collect time-stamped data and fit probability distributions to each. In conjunction with the initialization and validation steps, various regressions were performed to determine if any relationships existed between individual providers and patient types, length of stay, and the difference between discharge time and appointment time. The latter two statistics along with resource utilization and closing time were the primary metrics used to evaluate system performance.The results showed that up to an 8.5% reduction in patient length of stay is achievable without noticeably affecting the other metrics by carefully adjusting appointment times. Reducing the no-show rate from its current value of 21.8% or overbooking, however, is likely to overwhelm the system's resources and lead to excessive congestion and overtime. Another major finding was that the providers are the limiting factor in improving patient flow. With an average utilization rate above 90% there is little prospect in shortening the total patient time in the clinic without reducing the providers' average assessment time. Finally, several suggestions are offered to ensure fairness when dealing with out-of-order arrivals.

Burden of copy number variation in common variable immunodeficiency

Common variable immunodeficiency (CVID) has been associated recently with a dramatic increase in total copy number variation burden, the cause of which is unclear. In order to explore further the origin and clinical relevance of this finding, we quantified the total genomic copy number variation (CNV) burden in affected patients and evaluated clinical details in relationship to total CNV burden. No correlation was found between total CNV burden and either patient age or time elapsed since symptom onset, and higher total burden did not correlate with incidence of malignancy or other subphenotypes. These findings suggest that the increased CNV burden is static and intrinsic to CVID as a disease.

Administration and burden of subcutaneous immunotherapy for allergic rhinitis in clinical practice in Canada

Background Allergic rhinitis (AR) has been estimated to affect approximately 20–25% of Canadians. [1] Management of AR encompasses allergen avoidance, use of symptomatic medications, and allergen immunotherapy for patients unresponsive to other pharmacotherapy. [2,3] This study was conducted to characterize patients receiving subcutaneous immunotherapy (SCIT) and the SCIT administration process in Canada and the United States; Canadian results are presented. Methods A multi-center, prospective, observational study was conducted at 5 allergy clinics in Quebec and Ontario and 1 primary care clinic in Quebec from March-September 2012. Patients ≥6 years who were scheduled for SCIT on study days were invited to participate in the study. Patients enrolled in a clinical trial, receiving sublingual immunotherapy or allergic only to insect venom, latex, food, or drugs were excluded. Site and patient-specific information were captured via direct observation, questionnaires, and medical chart review. Costs were estimated from time and supply observation and query. Results A total of 294 patients were enrolled with a mean age of 44 years (4% <18 years and 9% ≥65 years). Of these, 59% were female, 81% Caucasian, 57% employed full-time and 30% reported household income ≥$100,000. Concomitant allergy medications were reported by 66% of patients; 25% used asthma medications .T wo-thirds of patients reported initiating SCIT because they desired a cure “once and for all” for their allergies. Primary symptoms at initiation of SCIT were nasal congestion (62%), rhinorrhea (59%), sneezing (35%) and itchy eyes (32%). Chart data indicated that patients received treatment for several different antigens (mean: 4; SD: 3); those most commonly noted were ragweed (82%), house dust mites (55%), grass (48%) and tree (48%). Sites reported a SCIT build-up phase requiring one injection/week over 12-52 weeks. The SCIT maintenance phase was reported as one injection/month over 4-5 years. Site-specific means (SDs) for total patient time in the clinic for SCIT ranged from 32 (11) to 49 (10) minutes, including a 30-minute required post-injection observation at all but one site. Average patient travel time to the office for SCIT was 20 (SD: 14) minutes. Mean time missed from work in the previous week was 0.7 hours. The direct costs of an injection ranged from $14 to $41 by site, with extract preparation or acquisition and administrative tasks the largest components. Conclusions

Reduction in Occupational and Patient Radiation Exposure from Myocardial Perfusion Imaging: Impact of Stress-Only Imaging and High-Efficiency SPECT Camera Technology

Recently introduced high-efficiency SPECT cameras have demonstrated the ability to reduce radiation exposure to patients undergoing myocardial perfusion imaging studies, especially when combined with stress-only imaging protocols. To date there have been no relevant studies examining the reduced occupational radiation exposure to medical staff. We sought to determine whether changes in stress myocardial perfusion imaging protocols and camera technology can reduce the occupational radiation exposure to the staff of a nuclear cardiology laboratory. Monthly radiation dosimeter readings from 4 nuclear technologists, 4 nurses, and 2 administrative employees were analyzed from two 12-mo periods: October 2007-September 2008 (period 1), before the use of high-efficiency SPECT, and October 2010-September 2011 (period 2), after high-efficiency SPECT was introduced. The average monthly dose equivalent in millirems (1 mrem = 0.01 mSv) was recorded from personal dosimeters worn on laboratory coats. The total activity of (99m)Tc used per month, mean (99m)Tc administered activity per patient, average number of patients per month, patient time spent in the laboratory, and proportion of stress-only studies were determined. There were 3,539 patients in period 1 and 3,898 in period 2. An approximately 40% reduction in the dose equivalent across all staff members occurred during this time (-16.9 and -16.2 mrem for nuclear technologists and nurses, respectively; P < 0.0001). During period 2, the total activity of (99m)Tc used per month decreased (10,746 vs. 7,174 mCi [1 mCi = 37 MBq], P < 0.0001), as did the mean (99m)Tc administered activity per patient (36.5 vs. 23.8 mCi, P < 0.0001). The percentage of patients having stress-only imaging increased (35% vs. 56%, P < 0.0001), and the total patient time spent in the laboratory decreased. Radiation dose equivalent levels were reduced in period 2 to 1%-7% of the allowed annual occupational dose equivalent. The combination of the use of high-efficiency SPECT technology and stress-only protocols resulted in a 34.7% reduction in mean total (99m)Tc administered activity between time periods, with camera technology being responsible for 39.2% of the reduction and stress-only protocols for 60.8%. A combination of high-efficiency SPECT technology and selective use of stress-only protocols significantly reduces the occupational radiation dose equivalent to the staff of a nuclear cardiology laboratory.

More Frequent Hemoglobin Measurements and More Frequent Epoetin Alfa Titrations Are Both Associated with Increased Epoetin Alfa Dose but Not More Time in Target Hemoglobin Range,

Abstract 4194For the past 20 years, management of hemoglobin (Hb) level via erythropoiesis-stimulating agents (ESAs), such as epoetin alfa (EPO) has been the norm in the care of end-stage renal disease (ESRD) patients. Recently, questions about patient safety and new economic bundling rules have brought renewed focus on appropriate Hb targets and how they relate to the use of EPO. Important issues related to Hb control are the frequency of Hb measurements, Hb value, the frequency of changes in EPO dose (titrations), and total EPO dose. Current practice aims to achieve greater control of Hb by more frequent measurement and finer EPO dose titrations. No studies have definitively shown that levels of titration and measurement frequency lead to better clinical outcomes or more efficient use of EPO. One large retrospective analysis found increasing Hb measurements and EPO dose titration frequency decreased patient variability around the facility-level Hb mean (Khan et al, 2011). However, a second study found that frequent titrations have been shown to be the most important driver of Hb cycling—potentially dangerous large fluctuations in Hb levels (Fishbane and Berns, 2005). The issue remains controversial.We conducted a retrospective database analysis in order to quantify the frequency of Hb dose titrations and measurements, and to evaluate their relationship to ESA dose and the ability to keep patients within a Hb range of 10–12 g/dL. Data from prevalent (≥ 120 days), adult (>18 years old) hemodialysis patients dialyzing at DaVita dialysis clinics ≥ 3 times per week between January 1, 2009 and December 31, 2010 were included.For every session, patients’ stable dosing periods were defined as any series of at least 3 doses during which the dose did not change more than 10% from first dose in the series. Dose holds were defined as ≥ 3 consecutive sessions with 0 EPO dose. An EPO dose of 0 lasting <3 consecutive sessions was ignored when identifying stable periods and holds. Doses not categorized as part of a stable period or a dose hold were considered transition periods. A dose titration was defined as a difference of > 10% between any of the following: the mean dose of 2 consecutive stable periods; the mean dose of stable period and next/previous dose in transition period; and 2 consecutive doses within a transition period. Transitions involving a dose hold were counted as 1 titration if the patient then returned to a dose within 10% of the mean of the prior period; or 2 titrations otherwise. Similar rules were developed for the minority of patients who received EPO once or twice per week. Correlations among measures (titrations/patient-month and Hb measurements/patient-month with mean monthly EPO dose and time with Hb in range) were assessed using Pearson product-moment correlation and linear regression (adjusted for racial composition, percentage of dialysis vascular access types, percentage with comorbidities, and mean age, vintage, and BMI) at the physician and the facility levels. Time in range was defined as total patient time in range/total patient-time. Facility level analyses were weighted by facility load (minimum of 300 patient-months) and are reported here.Information from 81,464 patients at 1,336 facilities was assessed. The mean number of titrations was 13.6 ± 2.83 (mean ± SD) per patient per year and the mean number of Hb measurements was 36.3 ± 8.24 per patient per year. The mean percent of patient-time in range among these facilities was 57.1% ± 5.8%. At the facility level, after adjustment for case mix factors (mean age, vintage, and BMI at facility, access types, and racial composition) the annual number of dose titrations per patient and Hb measurements per patient were not associated with the percent of patient-months within a 10–12 g/dL Hb range (p=0.12 and p=0.47; respectively). An analysis of ESA utilization showed that an increase of 1 titration per patient at the facility level was associated with an extra 18,000 U (p<0.001) per patient.In this retrospective study of >80,000 US dialysis patients over 2 years, neither increased Hb measurements nor increased EPO titrations were associated with improving patient-time in Hb range. However, increased EPO titrations were associated with significantly increased EPO utilization. Although these associations do not demonstrate causality (or the direction of potential causality), they do underscore the need to assess titration practices. Disclosures:Bond:DaVita Clinical Research: Employment; Affymax Inc: Research presented in this study was paid for by Affymax. Rubin:DaVita Clinical Research: Employment; Affymax: The research presented in this abstract was paid for by Affymax. Wang:DaVita Clinical Research: Employment; Affymax: The research presented in this abstract was paid for by Affymax. Yang:Affymax: Employment.

The impact of zoledronic acid therapy in survival of bladder cancer patients with bone metastasis.

e15096 Background: Bone metastases occur in almost 40% of patients with bladder cancer. M-VAC chemotherapy to bone metastasis has been done and median survival time is 10 months. (Bajorin, JCO 17, 3173, 1999). Recent studies demonstrate a direct antiproliferative effect of 3rd generation bisphosphonates (BPs) on bladder tumors, which may influence the survival. Therefore, we examined the clinical impact of zoledronic acid (ZOL; Zometa), a 3rd generation BP, with a focus on the survival, time to progression and pain effect in bladder cancer patients with bone metastases. Methods: Bladder cancer patients (n = 30, Stage IV) with evidence of metastasis bone scan were included. Fifteen patients of 30 experienced bone pain and received ZOL, 4 mg i.v. every 28 days (Group A), whereas the other 15 patients received no ZOL (Group B). All patients were treated with a combination chemotherapy consisted of gemcitabine 1000 mg/m(2) and carboplatin AUC = 6. Results: It was found that Group A had a statistically significant longer survival (p =0.003) when compared to Group B. Median survival time of Group A and Group B was 16 months and 7 months, respectively. A statistically significant positive correlation was found between the number of cycles of therapy with ZOL and total patient survival (p < 0.01, Pearson correlation) and time to progression (p < 0.01). Pain effect of ZOL had no significant difference between the 2 groups of patients (p > 0.05). Urine N-telopeptide of type I collagen (NTx) levels decreased in patients with NTx < or = 29 nM BCE/mM creatinine at baseline after treatment with ZOL. Conclusions: The results of our study suggest that the addition of ZOL increases overall survival in bladder cancer patients with bone metastases. The longer period of receiving ZOL, the better effect on survival and time to progression. Further clinical investigation is warranted. No significant financial relationships to disclose.

Revisiting the Cost-Effectiveness of the COMBINE Study for Alcohol Dependent Patients

Most cost and cost-effectiveness studies of substance abuse treatments focus on the costs to the provider/payer. Although this perspective is important, the costs incurred by patients should also be considered when evaluating treatment. This article presents estimates of patients' costs associated with the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) alcohol treatments and evaluates the treatments' cost-effectiveness from the patient perspective. A prospective cost-effectiveness study of patients in COMBINE, a randomized controlled clinical trial of 9 alternative alcohol treatment regimens involving 1383 patients with diagnoses of primary alcohol dependence across 11 US clinic sites. We followed a microcosting approach that allowed estimation of patients' costs for specific COMBINE treatment activities. The primary clinical outcomes from COMBINE are used as indicators of treatment effectiveness. The average total patient time devoted to treatment ranged from about 30 hours to 46 hours. Time spent traveling to and from treatment sessions and participation in self-help meetings accounted for the largest portion of patient time costs. The cost-effectiveness results indicate that 6 of the 9 treatments were economically dominated and only 3 treatments are potentially cost-effective depending on patient's willingness to pay for the considered outcomes: medical management (MM) + placebo, MM + naltrexone, and MM + naltrexone + acamprosate. Few studies consider the patient's perspective in estimating costs and cost-effectiveness even though these costs may have a substantial impact on a patient's treatment choice, ability to access treatment, or treatment adherence. For this study, the choice of the most cost-effective treatment depends on the value placed on the outcomes by the patient, and the conclusions drawn by the patient may differ from that of the provider/payer.

Emergency demand access block and patient safety: A call for national leadership

There is increasing pressure on ED caused by a relentless increase in ED attendances and rising emergency admissions. This is compounded by the challenge of reduced inpatient bed access. In this issue of Emergency Medicine Australasia, Richardson and colleagues confirm that access block is worsening, having increased nationally by an average of 27% over the 4 years to September 2008. Of interest is the reported improvement in patient flow attributed to the ‘patient journey’ project, despite continuing rising demand throughout this time period in New South Wales. It is not clear whether this has been sustained. Richardson et al. conclude that hospitals have possibly reached saturation point regarding efficiency in managing patient flow. These findings will be no surprise to ED clinical staff, who have consistently stated that the problem extends beyond the walls of individual hospitals. The causes for this access block are known and solutions are evident. It is now time that leadership is shown at both clinical and policy levels to stop the problem. The Australasian College for Emergency Medicine (ACEM) defines an excessive wait for an inpatient bed as greater than 8 h, the UK defines it as 4 h and Western Australia has followed suit. However, in the context of comparison within and between countries, it is pertinent to also consider how access block is defined and measured. For example, ACEM includes the time of arrival to departure from the ED in their calculation, whereas New South Wales Health has excluded ED waiting time, commencing their computation at the time the patient is attended to by a doctor. This latter measure fails to include time delay attributable to hold-up in processes associated with ED overcrowding, and therefore underestimates the overall delay experienced by the patient. The time is also subject to manipulation. There are many ways of measuring access block, including total patient time in ED, time from medical assessment to departure time and collective ‘total access block time’. It is essential for benchmarking to occur that all states collect data in a standardized fashion, which can be verified by outside agencies.

The impact of zoledronic acid therapy in survival of lung cancer patients with bone metastasis

Bone metastases occur in 20-40% of patients with lung cancer. Recent studies demonstrate a direct antiproliferative effect of 3rd generation bisphosphonates (BPs) on lung tumors, which may influence the survival. Therefore, we examined the clinical impact of zoledronic acid (ZOL; Zometa), a 3rd generation BP, with a focus on the survival, time to progression and pain effect in lung cancer patients with bone metastases. Lung cancer patients (n = 144, Stage IV) with evidence of metastasis bone scan were included. Eighty-seven of 144 experienced bone pain and received ZOL, 4 mg i.v. every 21 days (Group A), whereas the other 57 patients received no ZOL (Group B). All patients were treated with a combination chemotherapy consisted of docetaxel 100 mg/m(2) and carboplatin AUC = 6. It was found that Group A had a statistically significant longer survival (p < 0.01) when compared to Group B. A statistically significant positive correlation was found between the number of cycles of therapy with ZOL and total patient survival (p < 0.01, Pearson correlation) and time to progression (p < 0.01). Pain effect of ZOL had no significant difference between the 2 groups of patients (p > 0.05). Urine N-telopeptide of type I collagen (NTx) levels decreased in patients with NTx < or = 29 nM BCE/mM creatinine at baseline after treatment with ZOL. The results of our study suggest that the addition of ZOL increases overall survival in lung cancer patients with bone metastases. The longer period of receiving ZOL, the better effect on survival and time to progression.

Paper-based dosing algorithms for maintenance of warfarin anticoagulation

We examined the quality of anticoagulation produced by two paper-based warfarin dosing algorithms in a randomized clinical trial of warfarin therapy. Fifty-eight patients were randomized to receive warfarin at a target international normalized ratio (INR) range of 2.1-3.0 and were followed for an average of 2.7 years. As a proportion of total patient-time, the percentage of time spent above, within, and below the therapeutic range was 11%, 71%, and 19% respectively. Fifty-six patients were randomized to receive warfarin at a higher target INR range (3.1-4.0) and had INRs within the therapeutic range for 40% of total patient time. We conclude that the performance, minimal cost, and ease-of-use of these algorithms make them well-suited for patient management within primary-care and research settings.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.