Search

Cardiovascular disease (CVD) is a leading cause of death worldwide, with a higher burden in low- and middle-income countries (LMICs) compared to high-income countries. LMICs face challenges such as limited resources, poor health literacy, and inadequate healthcare infrastructure, which contribute to disparities in CVD care and outcomes. There is a need for global funding to address these disparities and support initiatives to strengthen health systems, expand access to cardiovascular services, and improve CVD research in LMICs. Technological advancements, such as mobile health and telemedicine, have the potential to improve cardiovascular care and outcomes in LMICs. Strategies to address global inequalities include point-of-care diagnostics, decentralization of care, telemedicine, and incorporating LMIC data into drug development. Policies promoting access, affordability, and home-based care are also necessary to protect under-resourced populations at risk of CVD. Contextualizing preventive and curative interventions and investing in manufacturing good-quality generics are key to reducing the burden of CVD in LMICs. [Extracted from the article]

Considerable variation exists in the delivery of acute stroke care and stroke outcomes across settings and population groups. This is attributable in part to variation in resources among emergency departments in the United States, most notably in rural regions. Structural constraints of the US health care system, including the geographic distribution of where patients live relative to the location of hospitals and certified stroke centers, will continue to mean that many patients with stroke initially present to community emergency departments that have fewer stroke-related resources. These sites also tend to serve populations in rural areas who experience disparities in care and outcomes. Reducing health disparities related to stroke for populations in rural areas requires investment in these more remote community settings as the anchor of the stroke chain of survival for their respective communities. This scientific statement performs a critical appraisal examining challenges in rural stroke care related to access and variation in stroke-related capabilities for the acute phase of care to inform strategies and propose solutions. The scientific statement considers the value of expansion of Acute Stroke Ready Hospital and Primary Stroke Center certification in rural areas, the role of telehealth and improved transfer processes, as well as increased engagement and mentorship from larger, comprehensive centers to the rural hospitals to which they are connected. Multistakeholder collaboration and policy interventions need to be directed to enhance public awareness, impart staff training, grow infrastructure, enhance access to clinical expertise, streamline data management, and implement quality assessment and improvement programs.

Purpose of Review: Access to and quality of kidney care is not equitable between or within countries. A natural question is whether global kidney care inequities are always unjustifiable and unfair, or are sometimes due to unavoidable competing or conflicting ethical duties or responsibilities., Recent Findings: Health is a fundamental right for all people. People with kidney conditions should have the same claim on this human right as others. Countries have an obligation to progressively fulfil this right and a duty to do so equitably, but global progress has been slow. Countries with limited resources or faced with humanitarian emergencies must set priorities to allocate resources fairly. This process involves trade-offs and often people requiring kidney replacement therapy are left out because of costs, logistics and lack of data. Major burdens are placed on clinicians who grapple between their duty to their patient and professional codes and their responsibility to a 'greater good'. These dilemmas apply also to industry, governments and the international community who must recognize their share in these duties., Summary: Inequities in kidney health and care must be acknowledged and sustainable and collaborative solutions urgently found such that right to kidney care is progressively upheld for everyone everywhere., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

A range of challenges exists regarding vitreoretinal (VR) surgical services in resource-limited settings, including Sierra Leone. As a result, retinal pathologies may contribute to vision loss and blindness. In the wake of the 2013 to 2016 outbreak of Ebola virus disease in West Africa, gaps in ophthalmic care were underscored as survivors were experiencing a constellation of sequelae, including uveitis and VR disease. Given the unmet needs in addressing VR disease, systems for retinal surgical care were required. To further understand long-term ocular complications in Ebola survivors and molecular and immunologic factors associated with this, research infrastructure was developed for retinal evaluation and surgery. The 5 "S'" framework was implemented and considered staff, space, stuff, systems, and social support. The ongoing development of retinal health infrastructure has helped to address challenges related to program implementation, development of surgical capacity, and alignment with local stakeholders and collaborator objectives. VR surgical services have been established in Sierra Leone through multidisciplinary partnerships and collaboration and serve patients in-country, as well as others in West Africa who have traveled for care. Continued engagement across stakeholders can aim to address challenges and promote effective care delivery., Competing Interests: The authors declare that they have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Screening for lung cancer is an evidence-based but underutilized measure to reduce the burden of lung cancer mortality. Lack of adequate data on geographic availability of lung cancer screening inhibits the ability of healthcare providers to help patients with decision-making and impedes equity-focused implementation of screening-supportive services. Objectives: This analysis used data from the 2012–2016 Surveillance, Epidemiology, and End Results (SEER) Program, the Behavioral Risk Factor Surveillance System, and the county health ranking to examine (a) which cancer resources and county-level factors are associated with late-stage lung cancer at diagnosis and (b) associations between county rurality and lung cancer incidence/mortality rates. Methods: Using the New York state SEER data, we identified 68,990 lung cancer patients aged 20–112 years; 48.3% had late-stage lung cancers, and the average lung cancer incidence and mortality rates were 70.7 and 46.2 per 100,000, respectively. There were 144 American College of Radiology-designated lung cancer screening centers and 376 Federally Qualified Health Centers identified in New York state. County rurality was associated with a higher proportion of late-stage lung cancers and higher lung cancer mortality rates. Discussion: Visual geomapping showed the scarcity of rural counties' healthcare resources. County rurality is a significant factor in differences in lung cancer screening resources and patient outcomes. Use of publicly available data with geospatial methods provides ways to identify areas for improvement, populations at risk, and additional infrastructure needs. [ABSTRACT FROM AUTHOR]

To predict the development of health resource allocation in Jilin Province during the 14th 5-Year Plan period, and to provide a scientific basis for promoting the improvement of its service capacity. The data of the health resource from 2015 to 2022 were obtained from the Jilin Statistical Yearbook, and the number of medical institutions, medical beds, health technicians, licensed (assistant) physicians, registered nurses and pharmacists were selected as evaluation indicators, and the grey prediction model constructed by Python was used to predict the development from 2023 to 2025. In the 14th 5-Year Plan period, the health resource in Jilin Province showed an increasing trend, and it is predicted that in 2025, the number of medical institutions, medical beds, health technicians, licensed (assistant) physicians, registered nurses, and pharmacists in Jilin Province will reach 28,999, 196,328, 262,219, 101,273, 129,586, and 9469, respectively. Except that the pharmacist team failed to meet the planning objectives of the 14th 5-Year Plan, the remaining health resources could meet the planning requirements. The allocation level of health resources in Jilin Province has been continuously improved, but it still faces the problems that the allocation of medical beds needs to be optimized, the doctor-nurse ratio needs to be improved, the reserve of registered nurses is insufficient, there is a gap in the pharmacist team, and the development of pharmacy services is slow., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Dr Simonsen reports grants from the Health Research Foundation of Central Denmark Region and speaker fee from Pfizer, outside the submitted work. Dr Blauenfeldt reports speaker fee from Novo Nordisk, Pfizer, and Bayer, outside the submitted work.

Background: Sex disparities exist in the management and outcomes of various cardiovascular diseases. However, little is known about sex differences in cardiogenic shock (CS). We sought to assess sex-related differences in the characteristics, resource utilization, and outcomes of patients with CS., Methods: The Critical Care Cardiology Trials Network is a multicenter registry of advanced cardiac intensive care units (CICUs) in North America. Between 2018 and 2022, each center (N=35) contributed annual 2-month snapshots of consecutive CICU admissions. Patients with CS were stratified as either CS after acute myocardial infarction or heart failure-related CS (HF-CS). Multivariable logistic regression was used for analyses., Results: Of the 22 869 admissions in the overall population, 4505 (20%) had CS. Among 3923 patients with CS due to ventricular failure (32% female), 1235 (31%) had CS after acute myocardial infarction and 2688 (69%) had HF-CS. Median sequential organ failure assessment scores did not differ by sex. Women with HF-CS had shorter CICU lengths of stay (4.5 versus 5.4 days; P <0.0001) and shorter overall lengths of hospital stay (10.9 versus 12.8 days; P <0.0001) than men. Women with HF-CS were less likely to receive pulmonary artery catheters (50% versus 55%; P <0.01) and mechanical circulatory support (26% versus 34%; P <0.0001) compared with men. Women with HF-CS had higher in-hospital mortality than men, even after adjusting for age, illness severity, and comorbidities (34% versus 23%; odds ratio, 1.76 [95% CI, 1.42-2.17]). In contrast, there were no significant sex differences in utilization of advanced CICU monitoring and interventions, or mortality, among patients with CS after acute myocardial infarction., Conclusions: Women with HF-CS had lower use of pulmonary artery catheters and mechanical circulatory support, shorter CICU lengths of stay, and higher in-hospital mortality than men, even after accounting for age, illness severity, and comorbidities. These data highlight the need to identify underlying reasons driving the differences in treatment decisions, so outcomes gaps in HF-CS can be understood and eliminated., Competing Interests: Drs Berg, Bohula, Park, and Morrow are members of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott, Abiomed, Amgen, Anthos Therapeutics, ARCA Biopharma, Inc, AstraZeneca, Bayer HealthCare Pharmaceuticals, Inc, Daiichi-Sankyo, Eisai, Intarcia, Ionis Pharmaceuticals, Inc, Janssen Research and Development, LLC, MedImmune, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron Pharmaceuticals, Inc, Roche, Siemens Healthcare Diagnostics, Inc, Softcell Medical Ltd, The Medicines Company, and Zora Biosciences. Dr Katz reports modest research funding from Abbott Corporation. The other authors report no conflicts.

Background: Burnout, depression, and anxiety are increasingly recognized as common among health care providers. Risks for these conditions are exacerbated in low-resource settings by excessive workload, high disease burden, resource shortage, and stigma against mental health issues. Based on discussions and requests to learn more about burnout during the Vital Anaesthesia Simulation Training (VAST), our team developed VAST Wellbeing, a 1-day course for health care providers in low-resource settings to recognize and mitigate burnout and to promote personal and professional well-being., Methods: This mixed-methods study used quantitative pre- and postcourse surveys using validated mental health measures and qualitative semistructured interviews to explore participants' experience of VAST Wellbeing during and after the course. Quantitative outcomes included burnout and professional fulfillment as measured by the Professional Fulfillment Index and general well-being as measured by the Warwick-Edinburgh Mental Wellbeing Scale., Results: Twenty-six participants from 9 countries completed the study. In the immediate postcourse survey, study participants rated the course overall as "very good" (60.7%) and "excellent" (28.6%). Quantitative analysis showed no statistical differences in levels of work exhaustion, interpersonal disengagement, burnout, professional fulfillment, or general mental well-being 2 months after the course. Five themes on the impact of VAST Wellbeing were identified during qualitative analysis: (1) raising awareness, breaking taboos; (2) not feeling alone; (3) permission and capacity for personal well-being; (4) workplace empowerment; and (5) VAST Wellbeing was relevant, authentic, and needed., Conclusions: Causes of burnout are complex and multidimensional. VAST Wellbeing did not change measures of burnout and fulfillment 2 months postcourse but did have a meaningful impact by raising awareness, reducing stigma, fostering connection, providing skills to prioritize personal well-being, and empowering people to seek workplace change., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Supervision of nonspecialist clinicians by trained mental health professionals is integral to developing capacity for providing mental health care in low-resource settings. Current supervision efforts in low-resource settings, however, are often variable in quality. Scant published literature addresses how supervision practices affect treatment outcomes; only a few studies have been published on evidence-based supervision methods. Additionally, in low-resource settings many systems-level obstacles exist in providing adequate mental health supervision to nonspecialist clinicians. This article seeks to address psychiatrists' role in providing supervision and promoting quality of care in low-resource settings. We review the literature on evidence-based supervision practices, address obstacles and current practices of providing high-quality mental health supervision in low-resource settings, and weave this knowledge with our experiences learning from the clinicians at Partners in Health in Haiti. We also discuss feasible strategies and provide recommendations for strengthening the supervision process in resource-limited settings. [ABSTRACT FROM AUTHOR]

Objectives: When healthcare systems are overwhelmed, accurate assessments of patients' predicted mortality risks are needed to ensure effective allocation of scarce resources. Organ dysfunction scores can serve this essential role, but their evaluation in this context has been limited so far. In this study, we sought to assess the performance of three organ dysfunction scores in both critically ill adults and children at clinically relevant mortality thresholds and timeframes for resource allocation and compare it with two published prioritization schemas.Design: Retrospective observational cohort study.Setting: Three large academic medical centers in the United States.Patients: Critically ill adults and children.Interventions: None.Measurements and Main Results: We calculated the daily Sequential Organ Failure Assessment score in adults and the Pediatric Logistic Organ Dysfunction 2 score and the Pediatric Sequential Organ Failure Assessment score in children. There were 49,290 (11.6% mortality) and 19,983 children (2.5% mortality) included in the analysis. Both the Sequential Organ Failure Assessment and Pediatric Sequential Organ Failure Assessment scores had adequate discrimination across relevant timeframes and adequate distribution across relevant mortality thresholds. Additionally, we found that the only published state prioritization schema that includes pediatric and adult patients had poor alignment of mortality risks, giving adults a systematic advantage over children.Conclusions: In the largest analysis of organ dysfunction scores in a general population of critically ill adults and children to date, we found that both the Sequential Organ Failure Assessment and Pediatric Sequential Organ Failure Assessment scores had adequate performance across relevant mortality thresholds and timeframes for resource allocation. Published prioritization schemas that include both pediatric and adult patients may put children at a disadvantage. Furthermore, the distribution of patient and mortality risk in the published schemas may not adequately stratify patients for some high-stakes allocation decisions. This information may be useful to bioethicists, healthcare leaders, and policy makers who are developing resource allocation policies for critically ill patients. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare no conflict of interest.

Rheumatic heart disease (RHD) affects ≈40 million people and claims nearly 300 000 lives each year. The historic passing of a World Health Assembly resolution on RHD in 2018 now mandates a coordinated global response. The American Heart Association is committed to serving as a global champion and leader in RHD care and prevention. Here, we pledge support in 5 key areas: (1) professional healthcare worker education and training, (2) technical support for the implementation of evidence-based strategies for rheumatic fever/RHD prevention, (3) access to essential medications and technologies, (4) research, and (5) advocacy to increase global awareness, resources, and capacity for RHD control. In bolstering the efforts of the American Heart Association to combat RHD, we hope to inspire others to collaborate, communicate, and contribute. [ABSTRACT FROM AUTHOR]

Objectives: This study assessed providers' present practices and perceived needs in Appalachian Kentucky to identify the standard of care and implementation of expert recommendations for managing pediatric obesity.Methods: Questionnaire data were gathered from 28 providers at a pediatric obesity continuing medical education workshop in eastern Kentucky. We assessed current practices, perceived barriers to treatment, and needed resources for managing pediatric obesity.Results: Respondents reported mixed adherence to expert recommendations, with providers less frequently addressing family-reported barriers to change and assessing a family's readiness to change behaviors related to pediatric obesity. Respondents also reported service barriers related to patient motivation, lack of time with patients, and a lack of referral options. Finally, providers reported needing multiple community resources to better address pediatric obesity, including improved physical education programs, access to community recreation centers, additional referral resources for multidisciplinary care, and additional training in motivational techniques.Conclusions: There remains a significant need for education and guidance regarding the implementation of expert recommendations for addressing pediatric obesity in Appalachian Kentucky. Providers reported needing multiple community resources, including improved physical education programs, access to community recreation centers, additional referral resources for multidisciplinary care, and additional training in motivational techniques. We discuss the implications for disseminating and implementing expert recommendations in rural eastern Kentucky, with an emphasis on the roles of behavioral health experts. [ABSTRACT FROM AUTHOR]

Objectives: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability.Methods: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural).Results: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends.Conclusions: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources. [ABSTRACT FROM AUTHOR]

By conducting an in-depth investigation and analysis of the health human resource framework within the Urumqi Center for Disease Control and Prevention (CDC), this study aims to offer valuable insights for the objective assessment and future enhancement of its talent development endeavors. A questionnaire survey was administered, followed by a descriptive analysis, involving the healthcare professionals affiliated with the Urumqi Center for CDC. The Urumqi Center for CDC exhibited a lower compilation number than its on-duty personnel count. When compared to county (district) level, the municipal level CDC displayed a higher educational attainment, a more favorable title distribution, and a younger workforce demographic. The human resource count in both Urumqi's city and county (district) level CDCs has decreased, but the relative numbers have improved, indicating enhanced quality and a younger workforce. The municipal-level CDC boasts a superior human resource structure compared to the county (district) level, with better fairness in population distribution by area than geography. Allocation equity within the central urban area is higher than in distant urban areas, highlighting regional disparities as a significant factor., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Both social service resources and stroke prevalence vary by geography, and health care resources are scarcer in rural areas. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of the highest stroke prevalence in Ohio and whether this is varied by rurality using an ecological study design., Methods: Census tract (CT)-level self-reported stroke prevalence estimates (Centers for Disease Control and Prevention PLACES-2019 Behavioral Risk Factor Surveillance System) were linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp data). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated the mean number of resources within 25 miles and 30 minutes of a CT centroid and quartiles of stroke prevalence for each resource group by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT demographics., Results: In Ohio, stroke prevalence was 3.9% (0.4%-14.2%). The highest stroke prevalence quartile (versus lowest) was associated with fewer resources within 25 miles overall (resource ratio [RR], 0.57-0.98). The most pronounced disparities were in rural CT; rural CTs with the highest quartile stroke prevalence had fewer housing (RR, 0.49 [95% CI, 0.32-0.75]), in-home (RR, 0.31 [95% CI, 0.20-0.49]), and therapy (RR, 0.23 [95% CI, 0.13-0.43]) resources compared with those with the lowest quartile stroke prevalence (reference: mean, 1.2 housing, 5.1 in-home, and 4.9 therapy resources, respectively). Rural disparities no longer persisted after adjustment for federal poverty limit (rural: housing [RR, 0.69 (95% CI, 0.40-1.20)], in-home [RR, 0.65 (95% CI, 0.34-1.23)], and therapy [RR, 0.66 (95% CI, 0.33-1.32)])., Conclusions: Stroke social service resources are inversely distributed relative to stroke prevalence in Ohio, particularly in rural areas. This inverse link in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions may be needed and should consider the roles of rurality and poverty., Competing Interests: Disclosures Dr Burke reports compensation from the American Heart Association for other services. The other authors report no conflicts.

Competing Interests: Disclosures None.

Introduction: Health care simulation technicians (HSTs), also referred to as simulation operations specialists, are essential to the delivery of simulation-based education. The HST role draws on a broad range of knowledge, skills, and attitude competencies. However, because of the neoteric nature of the HST role and the ambiguity surrounding the core responsibilities of the position, it has proved difficult to identify the competencies required to perform this role successfully. This study aims to identify the knowledge, skills, and attitude competencies required by HSTs., Methods: A mixed methods approach was used in this study. Data were collected from (1) online searches of HST job descriptions and (2) semistructured interviews about the competencies required by HSTs with 10 HSTs, 10 health care simulation educators, and 10 health care simulation center managers/director. The data from the job descriptions and interviews were analyzed using thematic analysis, using a framework method to guide the coding., Results: A total of 59 competencies were identified from the job descriptions and 65 competencies from the interviews. This analysis resulted in the identification of 9 competency domains: 3 knowledge domains (technical, clinical, and pedagogic), 4 skills domains (resourcefulness, pedagogic, team, and technical), and 2 attitudes domains (professional and "can-do" mentality)., Conclusions: The identification of the competencies required by HSTs will support the selection of candidates with the attributes that will allow them to be successful in this role and guide continuous professional development opportunities for current and future HSTs., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.)

Purpose of Review: To describe the current global burden of respiratory syncytial virus (RSV) in infants and its implications for morbidity, health resources and economic costs., Recent Findings: New prophylactic therapies are on the horizon for RSV in the form of long-acting monoclonal antibodies suitable for healthy infants and maternal immunizations., Summary: Despite being responsible for significant global infant morbidity and mortality, until recently there have been no effective therapeutics available for healthy infants to protect them from RSV. Several new drugs are likely to be available within the next few years which could help relieve a huge burden on healthcare systems over the coming winters., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Nighttime intensivist staffing does not improve patient outcomes in general ICUs. Few studies have examined the association between dedicated in-house 24/7 intensivist coverage on outcomes in specialized cardiac surgical ICUs. We sought to evaluate the association between 24/7 in-house intensivist-only management of cardiac surgical patients on postoperative complications and health resource utilization.Design: Before-and-after propensity matched cohort study.Setting: Tertiary care cardiac surgical ICU.Patients: Patients greater than 18 years old who underwent cardiac surgery between January 1, 2006, and April 30, 2013 (nighttime resident model), were propensity-matched (1:1) to patients from August 1, 2013, to December 31, 2014 (24/7 in-house intensivist model).Interventions: Cardiac surgical ICU coverage change from a nighttime resident physician coverage model to a 24/7 in-house intensivist staffing model.Measurements and Main Results: The primary outcome of interest was a composite of postoperative major complications. Secondary outcomes included duration of mechanical ventilation, all-cause cardiac surgical ICU readmissions, and surgical postponements attributed to lack of cardiac surgical ICU bed availability. A total of 1,509 patients during the nighttime resident model were matched to 1,509 patients during the intensivist model. The adjusted risk of major complications (26.3% vs 19.3%; odds ratio, 0.73; 95% CI, 0.36-0.85; p < 0.01), mean mechanical ventilation time (25.2 vs 19.4 hr; p < 0.01), cardiac surgical ICU readmissions (5.3% vs 1.6%; odds ratio, 0.31; 95% CI, 0.19-0.48; p < 0.01), and surgical postponements (3.4 vs 0.3 per mo; p < 0.01) were lower with the intensivist model.Conclusions: A transition to a 24/7 in-house intensivist care model was associated with a reduction in postoperative major complications, duration of mechanical ventilation, cardiac surgical ICU readmissions, and surgical postponements. These findings suggest that 24/7 intensivist physician care models may improve patient outcomes and health resource utilization in specialized cardiac surgical ICUs. [ABSTRACT FROM AUTHOR]

Community health workers advance health equity and foster community-clinical linkages. By promoting culturally relevant care, sharing their own stories, and bridging gaps, they can reach populations burdened with higher rates of chronic diseases due to adverse social determinants of health and structural racism. Given the disproportionate impacts of COVID-19, lessons learned from a forum, an expert group, and a survey showed a need by community health workers for (1) training, (2) health and safety practices, (3) workplace guidance, and (4) mental health resources. Community health workers are integral to expanding access to services and require a robust infrastructure for their growth., Competing Interests: The authors have no conflicts of interest.

Introduction: Patient-Centered Medical Home (PCMH) recognition is designed to promote whole-person team-based and integrated care., Purpose: Our goal was to assess changes in staffing infrastructure that promoted team-based and integrated care delivery before and after PCMH recognition in Health Resources & Services Administration (HRSA)-funded health centers (HCs)., Methodology/approach: We identified changes in staffing 2 years before and 3 years after PCMH recognition using 2010-2019 Uniform Data System data among three cohorts of HCs that received PCMH recognition in 2013 ( n = 346), 2014 ( n = 207), and 2015 ( n = 115). Our outcomes were team-based ratio (full-time equivalent medical and nonmedical providers and staff to one primary care physician) and a multidisciplinary staff ratio (allied medical and nonmedical staff to 1,000 patients). We used mixed-effects Poisson regression models., Results: The earlier cohorts served fewer complex patients and were larger before PCMH recognition. Three years following recognition, the 2013 and 2014 cohorts had significantly larger team-based ratios, and all three cohorts had significantly larger multidisciplinary staff ratios. Cohorts varied, however, in the type of staff that drove this change. Both ratios increased in the longer term., Conclusion: Our study suggests that growth in team-based and multidisciplinary staff ratios in each cohort may have been due to a combination of HCs' perceptions of need for specific services, HRSA funding, and technical assistance opportunities., Policy Implications: Further research is needed to understand barriers such as costs of employing a multidisciplinary staff, particularly those that cannot directly bill for services as well as whether such changes lead to practice transformation and improved quality of care., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Stroke center certification has evolved at a rapid pace and is now available at 4 different levels of service in the United States. Although certification standards provide guidance on stroke center process elements, lack of guidance on structural components such as workforce, staffing, and unit operations has resulted in heterogeneous services among hospitals credentialed at the same stroke center level. Such heterogeneity challenges public expectations and transparency about actual service capabilities within American stroke centers and in some cases may foster leniency in credentialing agency certification methods. Standards for other time-dependent diagnoses, including trauma, provide detailed guidance on structural elements that has improved patient triage and resuscitative care while enabling practitioners and administrators to more accurately gauge and plan service development to better support their communities. This scientific statement aims to provide similar structural guidance defined by each level of hospital stroke center services to reduce operational inconsistencies, to foster planning for service development, and to improve the interprofessional care of patients with acute stroke.

Background: The American Heart Association's 2020 Strategic Goals emphasize the value of optimizing risk factor status to reduce the burden of morbidity and mortality. In this study, we aimed to quantify the overall and marginal impact of favorable cardiovascular risk factor (CRF) profile on healthcare expenditure and resource utilization in the United States among those with and without cardiovascular disease (CVD).Methods and Results: The study population was derived from the 2012 Medical Expenditure Panel Survey (MEPS). Direct and indirect costs were calculated for all-cause healthcare resource utilization. Variables of interest included CVD diagnoses (coronary artery disease, stroke, peripheral artery disease, dysrhythmias, or heart failure), ascertained by International Classification of Diseases, Ninth Edition, Clinical Modification codes, and CRF profile (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical activity, and obesity). Two-part econometric models were used to study expenditure data. The final study sample consisted of 15 651 MEPS participants (58.5±12 years, 54% female). Overall, 5921 (37.8%) had optimal, 7002 (44.7%) had average, and 2728 (17.4%) had poor CRF profile, translating to 54.2, 64.1, and 24.9 million adults in United States, respectively. Significantly lower health expenditures were noted with favorable CRF profile across CVD status. Among study participants with established CVD, overall healthcare expenditures with optimal and average CRF profile were $5946 and $3731 less compared with those with poor CRF profile. The respective differences were $4031 and $2560 in those without CVD.Conclusions: Favorable CRF profile is associated with significantly lower medical expenditure and healthcare utilization among individuals with and without established CVD. [ABSTRACT FROM AUTHOR]

Purpose: The purposes of the study were to explore relationships between attitudes, beliefs, and practices of healthcare professionals caring for women and families experiencing miscarriage and to identify gaps and barriers in follow-up services and supports forthese women and families. Study Design and Methods: A survey about beliefs, attitudes, and practices regarding women and families experiencing miscarriage and barriers to care was conducted electronically and through distribution in three emergency departments (EDs). There were 174 participants; physicians (n = 50), RNs [ n = 63), midwives (n = 38), nurse practitioners (n = 9), and others [n = 4). Results: Participants believed that miscarriage can have high impact on women and families. They provided information to patients about miscarriage and its present and future implications. The most important predictor for mobilization of support by healthcare professionals was confidence. Nurses in EDs reported the least amount of confidence and knowledge to provide women and families with support. Availability and awareness of specific services by professionals and health system issues were identified as barriers to care. Clinical Implications: Education of healthcare professionals, particularly of RNs in EDs, is important to address misconceptions about miscarriage, increase confidence in providing support, and promote effective care. Women and families experiencing miscarriage need privacy and timeliness in care. Interventions such as funded midwifery loss care or a routine telephone follow-up call could improve access to care and help healthcare professionals ensure that families obtain the type and amount of support that they need. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective, single-center cohort study. Objective. To study how the systematic use of intraoperative skull- femoral traction (IOSFT) in posterior arthrodesis for adolescent idiopathic scoliosis impacts perioperative outcomes and health resource utilization. Summary of Background Data. Large scoliosis curves have been associated with increased morbidity and utilization of health resources. When used with reliable neurophysiological monitoring, IOSFT has shown to be safe and to reduce curve magnitude intraoperatively. Thus, we hypothesized that the systematic use of IOSFT may contribute to reducing health resource utilization by reducing curve magnitudes intraoperatively. Methods. Seventy-three consecutive patients with adolescent idiopathic scoliosis who underwent single-stage posterior spinal arthrodesis from 2008 to 2012 at a tertiary children's hospital were identified. Forty-five patients were operated with IOSFT (traction group) and 28 patients were operated without IOSFT (nontraction group). Outcome measures included operative time, calculated blood loss, blood transfusion requirement, traction-related complications, and cost comparisons. Results. Operative time was 375.6 minutes for the traction group (P = 0.0001) and 447.6 minutes for the nontraction group. Calculated blood loss was significantly less in the traction group (P = 0.027). Thirty-three percent of patients in the traction group required blood transfusion compared with 64% of patients in the nontraction group (P = 0.01, absolute risk reduction of 31%). There was no significant difference in curve magnitude correction (P = 0.49). There were no significant complications with the use of traction. There was a significant reduction in cost per surgical procedure in the traction group (P = 0.0003). Conclusion. The systematic use of IOSFT in posterior spinal arthrodesis for adolescent idiopathic scoliosis contributed to significant reductions in health resource utilization, with no added morbidity. Further research is warranted to investigate the generalizability of these findings. [ABSTRACT FROM AUTHOR]

Objective: ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Design: Retrospective database review. Setting: Academic, tertiary care, nontrauma surgical CU. Patients: All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. Interventions: None. Measurements and Main Results: Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (1 3.5±17.4 d) versus general surgery (8.7±12.9), transplant (7.8±11.6), oral-maxillofacial surgery (5.5±4.2), and neurosurgery (4.47±9.8) (all p <0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 1 0.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.00 1 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p <0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Conclusions: Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources. [ABSTRACT FROM AUTHOR]

In 2009, the Chalk River nuclear reactor closed for repairs that led to a critical shortage of technetium-99m (Tc-99m). Several centers used thallium-201 (Tl-201) as an alternative radiotracer for myocardial perfusion imaging. Because Tl-201 is considered by many as a suboptimal radiotracer, we sought to understand the impact of using Tl-201 (during the Tc-99m shortage) on downstream resource utilization.We performed a retrospective study at the Ottawa Heart Institute of 7402 patients (60% men; mean age, 62.6±11.8 years), patients were referred for myocardial perfusion imaging between May 2008 and January 2011 (PRE_Tc-99m [2938 patients]), during (DURING_Tl-201 [2959 patients]), and after (POST_Tc-99m [1505 patients]) the Tc-99m shortage. Patients were followed for 6 months after their index myocardial perfusion imaging to determine subsequent rates of cardiac catheterization or noninvasive imaging. More downstream testing was seen in the Tl-201 cohort (639 [21.4%] patients) than the Tc-99m cohort (537 [12.1%] patients; P<0.001). After adjustment using propensity scores, differences in downstream referral rates were maintained. The downstream investigations resulted in an estimated increase in per-patient costs ($165.22; 95% confidence interval, 153.00-177.42) in the DURING_Tl-201 cohort compared with the Tc-99m cohort ($90.97; 95% confidence interval, 83.42-98.90; P<0.001). As well, the mean effective radiation dose per-patient was higher in DURING_Tl-201 (23.57 mSv; 95% confidence interval, 23.16-23.96) than in Tc-99m (12.92 mSv; 95% confidence interval, 12.55-13.40; P<0.001).In this single-center study, the use of Tl-201 during the Tc-99m shortage was associated with an increase in downstream testing, cost, and patient radiation exposure, but these findings may not be generalizable to other centers. Although Tl-201 provided a short-term solution to the unexpected Tc-99m shortage, long-term cost-effective solutions should be areas of future study. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined if insurance coverage and race are associated with long-term acute care hospital utilization among critically ill patients requiring mechanical ventilation. The study utilized multivariable logistic regression with hospital-level random effects to examine the association between discharge to long-term acute care hospital, insurance status and race. It concluded that long-term acute care use after critical illness is influenced by insurance status.

The article examines the impact of data quality bias in health care quality assessment and the potential effects of misclassification on achieving gains in health care quality and equity. Approaches for the successful implementation of physician pay for performance (P4P) programs which acknowledge data quality bias are proposed. Measures for avoiding data quality bias in the medical pratice setting are discussed. The challenge of implementing performance-based reimbursement plans to medical practices is emphasized.

The article presents a study which aims to redesign the processes done at the computer tomography (CT) department in the Academic Medical Center in Amsterdam, the Netherlands, to decrease the access time for the CT-scan and simultaneously increase utilization level. Results have suggested that the promising and most feasible opportunity is to reallocate the insertion of intravenous access lines to a preparation room to reduce access time and improve utilization rate.

Organizational factors influence the quality of preventive care. Combining facility-level data from a national organizational survey and centrally available, externally abstracted chart review data on prevention performance, we assessed the relationship between structural features of primary care departments and the quality of preventive care delivered. Primary care practice resources were significantly and positively associated with the delivery of 6 of 9 preventive services. Adjusting for facility size and academic affiliation, these resource arrangements accounted for substantial variation in 8 of 9 services. Assuring high-quality prevention performance requires ongoing investment in primary care-based infrastructure. [ABSTRACT FROM AUTHOR]

The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision. Of 9741 anaesthesiologists' posts, 5694(58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practicing anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr. in 1989 to 45.9 yr. in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are corrently 14.75 anaesthesiologists per 100,000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals. Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the workplace, a redefinition of tasks and improved management of working time. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate postdischarge health resource use in pediatric survivors of septic shock and determine patient and hospitalization factors associated with health resource use., Design: Secondary analyses of a multicenter prospective observational cohort study., Setting: Twelve academic PICUs., Patients: Children greater than or equal to 1 month and less than 18 years old hospitalized for community-acquired septic shock who survived to 1 year., Interventions: None., Measurements and Main Results: For 308/338 patients (91%) with baseline and greater than or equal to one postdischarge survey, we evaluated readmission, emergency department (ED) visits, new medication class, and new device class use during the year after sepsis. Using negative binomial regression with bidirectional stepwise selection, we identified factors associated with each outcome. Median age was 7 years (interquartile range, 2-13), 157 (51%) had a chronic condition, and nearly all patients had insurance (private [n = 135; 44%] or government [n = 157; 51%]). During the year after sepsis, 128 patients (42%) were readmitted, 145 (47%) had an ED visit, 156 (51%) started a new medication class, and 102 (33%) instituted a new device class. Having a complex chronic condition was independently associated with readmission and ED visit. Documented infection and higher sum of Pediatric Logistic Organ Dysfunction--2 hematologic score were associated with readmission, whereas younger age and having a noncomplex chronic condition were associated with ED visit. Factors associated with new medication class use were private insurance, neurologic insult, and longer PICU stays. Factors associated with new device class use were preadmission chemotherapy or radiotherapy, presepsis Functional Status Scale score, and ventilation duration greater than or equal to 10 days. Of patients who had a new medication or device class, most had a readmission (56% and 61%) or ED visit (62% and 67%)., Conclusions: Children with septic shock represent a high-risk cohort with high-resource needs after discharge. Interventions and targeted outcomes to mitigate postdischarge resource use may differ based on patients' preexisting conditions., Competing Interests: Dr. Maddux’s institution received funding from the National Institute of Child Health and Human Development (NICHD) (K23HD096018) and the Francis Family Foundation. Drs. Maddux, Zimmerman, Banks, Reeder, Meert, Berg, Sapru, Carcillo, Newth, and Mourani received support for article research from the National Institutes of Health (NIH). Drs. Zimmerman’s, Banks’, and Carcillo’s institution received funding from the NICHD. Dr. Zimmerman’s institution received funding from Immunexpress; he received funding from Elsevier Publishing. Dr. Banks disclosed government work. Drs. Reeder’s, Meert’s, Berg’s, Sapru’s, Newth’s, and Mourani’s institutions received funding from the NIH. Dr. Czaja disclosed that she is a member of the critical care subboard for the American Board of Pediatrics. Dr. Carcillo’s institution received funding from the National Institute of General Medical Sciences. Dr. Newth received funding from Philips Research North America and Nihon Kohden. Dr. Mourani received funding from the NICHD (UG1HD083171). Dr. Quasney has disclosed that he does not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objective: Develop unifying definitions and paradigms for data-driven methods to augment postoperative resource intensity decisions., Summary Background Data: Postoperative level-of-care assignments and frequency of vital sign and laboratory measurements (ie, resource intensity) should align with patient acuity. Effective, data-driven decision-support platforms could improve value of care for millions of patients annually, but their development is hindered by the lack of salient definitions and paradigms., Methods: Embase, PubMed, and Web of Science were searched for articles describing patient acuity and resource intensity after inpatient surgery. Study quality was assessed using validated tools. Thirty-five studies were included and assimilated according to PRISMA guidelines., Results: Perioperative patient acuity is accurately represented by combinations of demographic, physiologic, and hospital-system variables as input features in models that capture complex, non-linear relationships. Intraoperative physiologic data enriche these representations. Triaging high-acuity patients to low-intensity care is associated with increased risk for mortality; triaging low-acuity patients to intensive care units (ICUs) has low value and imparts harm when other, valid requests for ICU admission are denied due to resource limitations, increasing their risk for unrecognized decompensation and failure-to-rescue. Providing high-intensity care for low-acuity patients may also confer harm through unnecessary testing and subsequent treatment of incidental findings, but there is insufficient evidence to evaluate this hypothesis. Compared with data-driven models, clinicians exhibit volatile performance in predicting complications and making postoperative resource intensity decisions., Conclusion: To optimize value, postoperative resource intensity decisions should align with precise, data-driven patient acuity assessments augmented by models that accurately represent complex, non-linear relationships among risk factors., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: This article aims to discuss the current state of resources enabling the democratization of artificial intelligence (AI) in ophthalmology., Recent Findings: Open datasets, efficient labeling techniques, code-free automated machine learning (AutoML) and cloud-based platforms for deployment are resources that enable clinicians with scarce resources to drive their own AI projects., Summary: Clinicians are the use-case experts who are best suited to drive AI projects tackling patient-relevant outcome measures. Taken together, open datasets, efficient labeling techniques, code-free AutoML and cloud platforms break the barriers for clinician-driven AI. As AI becomes increasingly democratized through such tools, clinicians and patients stand to benefit greatly., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no funding or conflicts of interest.

Subspecialization of critical care units and overall increasing demand for critical care services has led to inefficiencies in allocation of critical care resources with potential impacts on hospital economics and patient outcomes. Centralized management of critical care resource allocation within an institution may improve use while simultaneously ensuring quality of patient care. The authors' institution has implemented a Central Intensivist Physician (CIP) program to oversee resource allocation within the adult surgical intensive care units (ICUs). The result has been an improvement in patient flow throughout the surgical ICUs manifested by steady case cancellation rates despite increasing acuity and length of stay. Additionally, triage duties have been shifted from the individual unit physician to the CIP, resulting in improved provider satisfaction from improved continuity of rounds. The authors conclude that the CIP program may improve overall critical care resource use while maintaining unit specialization within a large tertiary care hospital setting. [ABSTRACT FROM AUTHOR]