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Objective To evaluate the effect of an arthritis center on patient care and operational throughput. Methods A single-institution, retrospective review was conducted of patients with hip or knee osteoarthritis from January 2016 to October 2019. Our physician assistant (PA) led arthritis center opened in November 2017, and manages nonoperative treatment of osteoarthritis by formulating individualized treatment plans. Descriptive and inferential statistics comparing operational measures, treatment patterns, and patient satisfaction pre- and postcenter opening were performed. Results Overall patient volume, new patient volume, and the proportion of new patients seen increased after the arthritis center opened. Encounters per patient and clinicians seen per patient decreased, while the rate of injections and surgery increased. Patient satisfaction improved after opening of the arthritis center. Conclusions The establishment of a dedicated PA-led arthritis center is associated with improved access to care, operational efficiency, and patient satisfaction in patients with hip and knee osteoarthritis.

Introduction This study examines the consequences of the COVID-19 pandemic on outpatient care in the German federal state of Brandenburg during the first ‘lockdown’ between 22 March and 4 May 2020, focusing on the burden for physicians and psychotherapists in outpatient practices and on alternative ways to provide care, in particular telehealth. Methods We conducted an online cross-sectional survey among outpatient health care professionals. The responses of n = 277 physicians and n = 87 psychotherapists were included in the analysis. Frequencies are shown; the relationship between categorical variables was examined using the χ2 test; we used a qualitative content analysis for free text answers. Results Almost all (96 %) physicians and 59 % of the psychotherapists reported a patient volume reduction since the COVID-19 outbreak. Cancellations were most often initiated by patients rather than physician offices. Among the physicians, routine check-ups and preventive care consultations were cancelled most frequently, and patients also appeared less frequently in open consultations. 72 % of the physicians and 29 % of the psychotherapists reported economic losses. While personal patient-physician contact was reduced, the use of telehealth has increased since the COVID-19 outbreak: during the first ‘lockdown’, two thirds of the psychotherapists (66 %) and 14 % of the physicians used telehealth for the first time. The COVID-19 pandemic contributed to a positive change in attitudes towards telehealth; this trend was significantly stronger among psychotherapists than among physicians. Discussion The reduction in patient volume shown in this study is confirmed by outpatient billing data analyses. Clinical routines changed due to COVID-19 and led to a growth in telehealth usage. By facilitating formal billing options, the increased use of telehealth can also be promoted after the pandemic. Conclusion Shortly after COVID-19 outbreak, outpatient physicians and psychotherapists were faced with various challenges: Through their spontaneous and flexible response to the COVD-19 pandemic, outpatient providers were able to maintain their work despite high stress levels. Telehealth is becoming more important as a result of COVID-19.

Purpose As costs continue to rise in oncology, a strategy that has been implemented to limit these costs is use of alternative sites of care. However, there are differences in regulatory standards between common sites of care such as freestanding infusion clinics and hospital outpatient departments. The costs associated with United States Pharmacopeia compliance were evaluated in order to better understand the cost of universally compliant hospital outpatient departments. Methods Annual operational costs associated with United States Pharmacopeia compliance were estimated for a 30-chair infusion clinic with United States Pharmacopeia and pharmacy cleanrooms for non-hazardous and hazardous drugs, respectively. Annual United States Pharmacopeia compliance costs included: competency assessments, personal protective equipment, closed system transfer devices, labels, cleaning supplies, and environmental monitoring. One-time costs included initial cleanroom construction and renovations. Published information and benchmarks provided baseline assumptions for patient volume, staffing, and unit costs. If no published data was available, prices were estimated based on a similarly sized clinic. Results Recurring annual costs for a 30-chair fully compliant infusion clinic were calculated to be $785,207. One-time costs associated with initial construction and renovations were estimated to be $1,365,207–$1,535,207 and $965,207–$1,005,207, respectively. Conclusions Costs associated with increased operational oversight and regulatory standards are a major contributing factor to the facility fee of hospital outpatient departments. Ultimately, all sites of care share in the goal to provide optimal patient care while considering all aspects of patient care, including cost. Therefore, a move towards consistent regulatory standards across all settings would aid in preventing discrepancies in care.

Study objective One proposed solution to prolonged emergency department (ED) wait times is a publicly available website that displays estimated ED wait times. This could provide information to patients so that they may choose sites with low wait times, which has the potential to smooth the overall wait times in EDs across a health system. We describe the effect of a novel city-wide ED wait time website on patient volume distributions throughout the city of Hamilton, Ontario, Canada. Methods We compared the number of new patients arriving every 15 minutes during 2 separate time periods—before and after a publicly viewable wait time website was made available. For each ED site, the effect of the posted wait time was measured by assessing its association with the total number of patient arrivals in the subsequent hour at the same site and at all other sites in Hamilton. Results Linear models showed clinically modest changes in patient volumes when wait times changed. However, nonlinear models showed that a 60-minute increase in wait time at a site was associated with 10% fewer patients presenting over the next hour. Larger negative associations were observed at community hospitals and urgent care centers. Increases in wait times at a given site were also associated with increased patient volumes at other sites in the system. Conclusion After the implementation of a public wait time website, elevated wait times led to fewer patients at the same site but more patient visits at other sites. This may be consistent with the wait time tracker inducing patients to avoid sites with high wait times and instead visit alternate sites in Hamilton, but only when wait times were very high.

To accommodate for the rapidly increasing patient volume and follow-up visits of men with prostate cancer on active surveillance (AS), we carried out a quality improvement project to secure high-quality care and enhance patient experience.We proposed an innovative clinic systems redesign - "Shared Medical Appointments" (SMAs) - in which multiple patients were seen in a group format at the same time by the health care team led by a urologist leading the Institution's AS program.We piloted four SMAs during July-November 2019. Running the SMAs was feasible and improved the contact time for each patient while at the same time being time- and resource efficient for the healthcare providers and using the standard billing processes. The group dynamic was open and pleasant. The majority of patients rated their overall experience with SMA as excellent. Almost all patients responded that they were likely or very likely to attend another SMA in the future. All patients said that they would either definitely or probably recommend this visit type to a friend of family member with prostate cancer. Most patients rated their overall satisfaction with the SMA as extremely high.Utilizing SMAs for AS follow-up visits was feasible and acceptable. Our promising findings suggest that SMAs can ensure high-quality patient care. Well-controlled studies comparing SMAs to individual usual care visits should be conducted with endpoints including knowledge, patient and staff satisfaction, anxiety and quality-of-life outcomes, AS adherence, process measures and resource utilization.

Összefoglaló. Bevezetés: Az elmúlt évtizedekben számos országban jelentős mértékben változott a hasi aortaaneurysmák sebészi kezelése az eredményesebb ellátás céljából: endovascularis beavatkozások terjedése, nagy betegforgalmú aortacentrumok kialakítása. Célkitűzés: A Magyarországon, infrarenalis aortaaneurysmák miatt végzett beavatkozások rövid távú eredményeinek elemzése elsősorban műtéti technika (endovascularis vs. nyitott aortareconstructio), intézeti betegforgalom (kis vs. nagy betegforgalmú intézet) és időszak (2010–2014 vs. 2015–2019) alapján. Módszer: A Nemzeti Érsebészeti Regiszterben 2010. 01. 01. és 2019. 12. 31. között prospektíven rögzített multicentrikus adatok retrospektív feldolgozása. Eredmények: A regiszterben 3206 infrarenalis aortaaneurysma-műtétet rögzítettek. A második öt évben jelentősen nőtt az endovascularis aortareconstructio aránya a nyitotthoz képest (pKövetkeztetés: Endovascularis aortareconstructio és nagy betegforgalmú intézetek esetében szignifikánsan alacsonyabb perioperatív mortalitás érhető el. Orv Hetil. 2021; 162(31): 1233–1243. Summary. Introduction: The organisation of aortic disease care has changed significantly in many countries over the last decade: centralized, high-volume centers were established. Objective: To analyse the perioperative mortality and the number of the infrarenal aortic aneurysm repairs according to the type of procedure (endovascular vs. open), patient volume (low vs. high) and time period (2010–2014 vs. 2015–2019). Methods: The multicentric data registered prospectively in the Hungarian National Vascular Registry between 01. 01. 2010 and 31. 12. 2019 were analysed retrospectively. Results: 3206 infrarenal aortic aneurysms were recorded. The endovascular-open repair rate was significantly higher (pConclusion: Endovascular repair and aortic surgery in the high-volume institutes result in significantly lower perioperative mortality. Orv Hetil. 2021; 162(31): 1233–1243.

Cadmium Zinc Telluride (CZT) crystal-based myocardial perfusion imaging (MPI) cameras have increased count sensitivity compared to Anger cameras and can be used to lower either the injected activity or the image acquisition time. Institutions adopting CZT cameras need to decide whether to lower the injected activity or imaging time or attempt to lower both with a compromise. The aim of our study was to compare the scan time required to obtain similar count images using high activity protocol (HAP) versus low activity protocol (LAP) stratified by body mass index (BMI) and assess the impact on effective dose and our clinic workflow. Using a CZT camera, a cohort of 100 consecutive clinical patients imaged with LAP rest-stress MPI with approximately 185 MBq and 555 MBq activity was retrospectively compared to a similar cohort of 100 consecutive clinical patients imaged with HAP rest-stress MPI using approximately 370 MBq and 1110 MBq. Administered activity and BMI both had a statistically significant effect on scan time and radiation effective dose. LAP scans took an average of 9 min longer than HAP scans overall, P < 0.0001 and larger BMIs took longer than smaller BMIs, P < 0.0001. In addition, scan times were longer in men than women, P = 0.007. Effective dose was inversely proportional to BMI with an overall decrease of approximately 50% comparing LAP to HAP. For the same CZT camera, the LAP increased scan time while lowering the radiation effective dose when compared to HAP. The increase in scan time increased proportionally to BMI. The effective dose was inversely proportional to BMI. This increase in time did not have a significant impact on our local workflow, but its implications should be considered in the setting of LAP implementation, especially in obese or high patient volume practices.

Background: Admissions for acute myocardial infarction (MI) have declined significantly during the COVID-19 pandemic. The changes in the presentation, management, and outcomes of MI during the pandemic period are not well recognized, and data from low- and middle-income countries are limited. Methods: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with MI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We sought to determine the changes in the number of admissions, management practices, and outcomes. Findings: We included 41,832 consecutive adults with MI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India with the North zone reporting greater decline (-44·8%) than the South zone (-27·7%). The weekly average decrease in MI admissions in 2020 which peaked around the mid- study period, correlated negatively with the number of COVID cases (r = -0·48; r 2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r 2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume, and teaching programs. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. However, the in-hospital mortality rates did not differ. Interpretation: The magnitude of reduction in MI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing MI admissions during the pandemic. Funding Statement: The study is funded by cardiological society of India. Declaration of Interests: Nothing to declare for all the authors. Ethics Approval Statement: Individual participating centres either obtained an ethical approval from respective Institutional ethics committees or a no objection certificate from the administration.

Background: On March 16, 2020, the first death from CO­VID-19 was recorded in Portugal. Since then, there has been a reorganization of health services, changing the normal approach for the different cases of public health. Excess deaths recorded without a COVID-19 diagnosis are called excess mortality without COVID-19 (EM non-COVID-19). This study aims to estimate the EM non-COVID in the 7-month period after the first registered Covid-19 death. Methods: The following 2 methods were used to estimate the excess mortality in this period: the daily historical average of reported deaths and an adapted auto regressive integrated moving average (ARIMA) model, considering the previous 5 years of records until October 16. For this model, after March 16, data was replaced with the daily historical average deaths from the previous 5 years, simulating the closest scenario possible as there was no pandemic. Only deaths from natural causes were selected for these estimations. For EM non-COVID-19 estimation, we subtracted the COVID-19 deaths from the overall excess mortality. Results: Between March 16, 2020, and October 16, 2020, there was an excess of 6,330 deaths from natural causes, i.e., nearly 12% more than expected. Both methods estimated an EM non-COVID-19 of around 66–67% in this period, with a greater relevance in mid-July and mid-September. Conclusions: Excess mortality was present almost every day during the study period. EM non-COVID-19 seemed to vary over time, showing some inadequacy of healthcare services in management of other patients free of COVID-19 in Portugal during periods with a greater patient volume. It is necessary to take care and monitor COVID-19 cases but also non-COVID-19 cases.

BACKGROUND: The imbalance between the increase in the overall volume of patients at the emergency department (ED) with the capacity of the emergency unit can lead to overcrowded conditions in the ED. Factors that cause ED density include lack of beds for inpatients, increased overall patient volume, increased non-emergency patient visits, lack of nursing staff, and lack of administrative support. Overcrowded at the ED can cause work stress on nurses. Nurses in the ED tend to experience more stress than nurses on the ward due to workload and work fatigue. AIM: This study aimed to investigate the correlation between the ED density with nursing work stress. METHODS: This study was conducted a correlational study in a hospital at Central Java in 2020. Total sampling with the criteria of nurses in the ED was the method employed to the respondents. The data analysis used descriptive statistics and rank Spearman, with a significant level of p < 0.05. RESULTS: The most frequent occurred in the ED was overcrowded, while nursing work stress was moderate stress. The result of the rank Spearman test obtained p = 0.000 with a correlation coefficient of 0.725. CONCLUSION: There was a significant correlation between the ED density levels with nursing work stress.

Introdução: As perturbações do neurodesenvolvimento são, nas sociedades modernas, as patologias crónicas mais frequentes da idade pediátrica. Muitas permanecem na vida adulta. A organização da rede de cuidados de saúde nacional carece de conhecimento fundamentado das necessidades assistenciais para lhes responder de um modo eficaz, eficiente e efetivo. Com o objetivo de conhecer a realidade assistencial hospitalar atual da Pediatria do Neurodesenvolvimento, a Sociedade de Pediatria do Neurodesenvolvimento da Sociedade Portuguesa de Pediatria procedeu a um levantamento nacional em 2007, repetindo-o dez anos depois.Material e Métodos: No biénio 2016-2017 procedeu-se a um inquérito dirigido ao universo de 45 unidades hospitalares abrangendo o movimento assistencial das consultas de Pediatria do Neurodesenvolvimento, a alocação de recursos humanos, e as necessidades de reforço de profissionais.Resultados: Obteve-se 100% de respostas. O número total de consultas de Pediatria do Neurodesenvolvimento subiu de 38 238 (2007) para 99 815 (2017). O número de profissionais também aumentou: os pediatras passaram de 82 a 156. Uma mediana de 101 crianças aguardavam primeira consulta, contra 185 em 2007.Discussão: Numa década, o movimento assistencial quase triplicou. O reforço de profissionais, apesar de positivo, não teve o mesmo incremento; ainda assim, o número de crianças em lista de espera para primeira consulta reduziu-se quase para metade, o que reflete o comprometimento dos profissionais.Conclusão: É de salientar a melhoria global da resposta nacional na área da Pediatria do Neurodesenvolvimento. Contudo, o reforço dos recursos humanos numa perspectiva pluridisciplinar não deve ser negligenciado, tendo em vista a melhoria contínua da prestação de cuidados numa área de grande cronicidade e complexidade.

Background Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. Our objective was to determine whether people with dementia receive lower-quality care if their primary care physician sees many patients daily. Methods Population-based retrospective cohort study using health administrative data from 100,256 community-living adults with dementia aged 66 years or older, and the 8,368 primary care physicians who cared for them in Ontario, Canada. Multivariable Poisson GEE regression models tested whether physicians’ daily patient volume was associated with the adjusted likelihood of people with dementia receiving vaccinations, prescriptions for cholinesterase inhibitors, benzodiazepines, and antipsychotics from their primary care physician. Results People with dementia whose primary care physicians saw ≥ 30 patients daily were 32% (95% CI: 23% to 41%, p p p = 0.02) less likely to receive influenza vaccination and 8% (95% CI: 4% to 13%, p = 0.0001) more likely to be prescribed cholinesterase inhibitors if their primary care physician saw ≥ 30 versus Conclusions People with dementia were more likely to receive both potentially harmful and potentially beneficial medications, and slightly less likely to be vaccinated by high-volume primary care physicians.

Emergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality-the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures.We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume.A total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r = 0.1774; p-value: 0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p 0.0001) after adjustment for other hospital level crowding indicators.We found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.

Purpose: The EORTC Radiation Oncology Group uses a Facility Questionnaire (FQ) to collect information from its member radiation oncology departments. We analysed the FQ database for patient-related workload, staffing levels and infrastructure to determine developments in radiation oncology departments in the clinical trials community. Materials & Methods: We exported the FQ database in August 2019. Departments were included if their FQ was created or updated within the two preceding years. Observations were compared with previous evaluations of the FQ database. Results: In total, 161 departments from 24 mostly European countries were analysed. The average number of patients per department increased by 3.0% to 2,453 (2013: 2,381). The annual number of patients decreased by 7.4% to 225 per radiation oncologist (2013: 243) and by 7.9% to 326 per medical physicist (2013: 354). In contrast, the number of patients increased by 23.3% to 106 per radiation therapist (RTT) (2013: 86) and per treatment unit by 3.9 % to 485 (2013: 467). In a pairwise comparison of departments that were available in 2013 and 2019, the number of patients per radiation oncologist (p = 0.02) and per physicist (p = 0.0003) decreased significantly. The number of departments that own a dedicated PET-CT scanner more than doubled (2013: 4%; 2019: 9%) and the availability of stereotactic body radiation therapy (SBRT) increased by 31.8% to 85.7% of the departments (2013: 65%). Conclusion: The case-related workload per radiation oncologist and per physicist continues to decrease but increases per RTT and treatment unit. This is likely driven by an increased use of complex techniques, multimodality imaging and the implementation of automation in radiation oncology departments. (C) 2020 Elsevier B.V. All rights reserved.

The arrival of the COVID-19 pandemic to hospitals in New York City stressed our emergency departments (ED) with high patient volume, stresses on hospital resources and the arrival of numerous high acuity, critically ill patients. Amid this time, we sought to leverage the ED Information Systems (EDIS), to assist in connecting critically ill patients, their families, and providers in the ED with palliative care resources. We discuss 4 innovative, thoughtful solutions to assist ED providers in identifying and addressing the acute and unique palliative care needs of COVID patients.

The COVID-19 pandemic necessitated a rapid transition from in-person office visits to virtual visits in the Down syndrome specialty program at Massachusetts General Hospital (MGH DSP). We describe the clinic transition to virtual visits in April 2020 and reflect on our six-month experience in virtual visits. Clinic metrics were tracked. Electronic survey responses were collected from caregivers attending virtual visits. Input from the MGH DSP team was collected. From April to September 2020, we maintained patient volume (45 visits per month) and overall satisfaction score (6.7 out of 7) following a sudden, unanticipated transition to virtual visits. Survey of 17 caregivers attending virtual visits found that most were equipped with technology, had access to a private location, and most were able to access visit without any limitations. Caregivers appreciated the convenience of virtual visits but sometimes missed the personal connection of an in-person visit. Overall, though, virtual visits were frequently viewed as no different than office visits. Team members identified benefits and challenges of virtual visits, as well as lessons learned from this transition. We were able to maintain multidisciplinary, specialty care with optimal caregiver feedback and sustained number of patient visits.

PURPOSE To identify barriers and facilitators to adopting deep anterior lamellar keratoplasty (DALK) for nonendothelial corneal pathology. METHODS An anonymous survey consisting of 22 multiple choice and free text questions was designed to gather information on demographic factors of surgeons and DALK surgical practices. The survey was emailed to members of the kera-net, a global online corneal surgeon/surgery platform. RESULTS A total of 100 surgeons completed the survey, most of whom practice in the United States (73%). Most surgeons (89%) reported performing DALK. Surgeons who did not learn DALK during fellowship (34%) tended to be in practice for higher numbers of years (P < 0.001). Surgeons in private practice are more likely to perform DALK versus those in other settings (92.7% vs. 80.8%, P = 0.087). Surgeons performing more corneal surgeries (at least 100 per year) are more likely to perform DALK than those who perform fewer than 100 per year (52% vs. 14%, P = 0.01). Surgeons who perform Descemet membrane endothelial keratoplasty are more likely to perform DALK than those who do not (81.7% vs. 18.3%, P = 0.014). There was also a positive correlation between PK and DALK surgical volumes (Spearman rank correlation coefficient = 0.57, P < 0.001). The main reasons for surgeon preference for DALK over PK were a desire to preserve the endothelium, intraoperative safety, and decreased complications. Longer surgical time and low patient volume were cited as barriers to adoption of DALK. CONCLUSIONS Alterations in DALK technique that reduce surgical time and providing more learning opportunities for DALK might improve adoption.

Introduction Version 2 of the Needs-Based Assessment of Trauma Systems (NBATS) tool quantifies the impact of an additional trauma center on a region. This study applies NBATS-2 to a system where an additional trauma center was added to compare the tool’s predictions to actual patient volumes. Methods Injury data were collected from the trauma registry of the initial (legacy) center and analyzed geographically using ArcGIS. From 2012 to 2014 (“pre-”period), one Level 1 trauma center existed. From 2016 to 2018 (“post-”period), an additional Level 2 center existed. Emergency medical service (EMS) destination guidelines did not change and favored the legacy center for severely injured patients (Injury Severity Score (ISS) >15). NBATS-2 predicted volume was compared to the actual volume received at the legacy center in the post-period. Results 4068 patients were identified across 14 counties. In the pre-period, 72% of the population and 90% of injuries were within a 45-minute drive of the legacy trauma center. In the post-period, 75% of the total population and 90% of injuries were within 45 minutes of either trauma center. The post-predicted volume of severely injured patients at the legacy center was 434, but the actual number was 809. For minor injuries (ISS £15), NBATS-2 predicted 581 vs. 1677 actual. Conclusion NBATS-2 failed to predict the post-period volume changes. Without a change in EMS destination guidelines, this finding was not surprising for severely injured patients. However, the 288% increase in volume of minor injuries was unexpected. NBATS-2 must be refined to assess the impact of local factors on patient volume.

Waldenstrom macroglobulinemia (WM) has an annual incidence of 3-3.2 cases per million-person/year. National Cancer Data Base was used to identify newly diagnosed WM cases requiring initiation of therapy and their annual facility volume was used to divide the treatment facilities into four quartiles (Qs). Cox regression was used to analyze the association between facility volume and survival, adjusted by demographics, socioeconomic, geographic, comorbidity factors and year of diagnosis. A total of 3064 patients treated in 795 facilities were included. The unadjusted median overall survival (OS) by facility volume was: Q1:6.5 years (5-year OS 55%), Q2:7 years (5-year OS 60%), Q3:8 years (5-year OS 64%), and Q4: NR (5-year OS 71%)

Stroke is a catastrophic medical disease with roughly 795,000 cases per year in the US. We strove to explore whether stroke admissions to a comprehensive stroke center in an area with moderately-low COVID-19 burden changed and if so, to better define the characteristics of the patients and their presentation. We performed a retrospective analysis of all patients with strokes admitted to Intermountain Medical Center. There was a 43% reduction in patients’ presentations across all stroke types compared to average April patient volume over the prior 3 years. Likely this was due to a myriad of complex factors which we may retrospectively be able to more fully understand in the years to come.

BACKGROUND: The effects of improvement (implementation and de-implementation) interventions are often modest. Although positive and negative deviance studies have been extensively used in improvement science and quality improvement efforts, conceptual and methodological innovations are needed to improve our ability to use information about variation in quality to design more effective interventions. OBJECTIVE: We describe a novel mixed methods extension of the deviance study we term “delta studies.” Delta studies seek to quantitatively identify sites that have recently changed from low performers to high performers, or vice versa, in order to qualitatively learn about active strategies that produced recent change, challenges change agents faced and how they overcame them, and where applicable, the causes of recent deterioration in performance—information intended to inform the design of improvement interventions for deployment in low performing sites. We provide examples of lessons learned from this method that may have been missed with traditional positive or negative deviance designs. DESIGN: Considerations for quantitatively identifying delta sites are described including which quality metrics to track, over what timeframe to observe change, how to account for reliability of observed change, consideration of patient volume and initial performance as implementation context factors, and how to define clinically meaningful change. Methods to adapt qualitative protocols by integrating quantitative information about change in performance are also presented. We provide sample data and R code that can be used to graphically display distributions of initial status, change, and volume that are essential to delta studies. PARTICIPANTS: Patients and facilities of the US Veterans Health Administration. KEY RESULTS: As an example, we discuss what decisions we made regarding the delta study design considerations in a funded study of low-value preoperative testing. The method helped us find sites that had recently reduced the burden of low-value testing, and learn about the strategies they employed and challenges they faced. CONCLUSIONS: The delta study concept is a promising mixed methods innovation to efficiently and effectively identify improvement strategies and other factors that have actually produced change in real-world settings. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06199-x) contains supplementary material, which is available to authorized users.

Objectives To examine the association between service volume and guideline adherence via multiyear observations. Study design Repeated cross-sectional study. Methods This study employed nationwide claims data from Taiwan's National Health Insurance scheme and identified patients with newly diagnosed type 2 diabetes from 2001, 2005, and 2009; a new prescription guideline for diabetes care was introduced in 2006. Physician service volume was measured by the number of total outpatients with diabetes. The outcome variable indicated whether a patient was receiving metformin, the guideline-recommended antihyperglycemic agent, at the index date. Results Patients visiting physicians who had high or medium volumes of patients with diabetes were more likely to receive metformin than patients visiting physicians who had low volumes; the odds ratios (ORs) were 2.48 (95% CI, 2.03-3.04) and 1.76 (95% CI, 1.45-2.13), respectively. Patients with newly diagnosed diabetes in 2009 and 2005 were more likely to receive metformin than their counterparts in 2001, with ORs of 12.00 (95% CI, 11.19-12.86) and 2.44 (95% CI, 2.30-2.59), respectively. We also found that patients who visited younger physicians, physicians with fewer practice years, physicians practicing in large-scale hospitals, or physicians practicing in urban areas were more likely to receive metformin than their counterparts. Conclusions In the process of implementing a new practice guideline for treating patients with diabetes, physicians with higher patient volumes are more likely to adhere to the guideline recommendation.

Cancer genetics clinics have seen increasing demand, challenging genetic counselors (GCs) to increase efficiency and prompting some clinics to implement genetic counseling assistants (GCAs). To evaluate the impact of GCAs on Geisinger’s cancer genetics clinic, we tracked GC time utilization, new patient volume, and clinic cost per patient before and after implementing a GCA program. GCs used time-tracking software while completing preappointment activities. Electronic health records were reviewed for appointment length and number of patients per week. Internal salary data for GCs and GCAs were used to calculate clinic costs per patient. Time spent by GCs completing each preappointment activity (21.8 vs. 15.1 minutes) and appointment length (51.6 vs. 44.5 minutes) significantly decreased after GCA program implementation (p values < 0.001). New patients per week per GC significantly increased (7.9 vs. 11.4, p

Crowding in emergency departments (EDs) is a concern for hospital administrators, emergency providers, and patients. Many factors contribute to crowding, including variable patient volume and acuity along with contributing hospital factors such as inadequate nursing support and insufficient inpatient beds resulting in prolonged ED boarding times.1 In order to better study and define characteristics indicative of crowding, the National Emergency Department Overcrowding Study (NEDOCS) established a standardized and validated scoring system to quantify crowding in an academic setting.2 Although individual components attributed to crowding and patient satisfaction have been studied,3-5 including studies utilizing the NEDOCS score in relation to patient satisfaction,6 none to our knowledge have investigated the Press Ganey Associates, Inc (PGA) surveys and NEDOCS scores.

The evolving healthcare landscape creates unique challenges for private practitioners. They experience the same issues that face physicians in general - including increased regulatory/documentation burdens and downward financial pressures - but without the safety nets that exist in larger healthcare systems. Costs are born more directly, as there are fewer providers over which to spread expenditures. Financial reserves are less robust, making margins thinner to maintain profitability. Guaranteed referral streams are absent, requiring additional effort and creative solutions to maintain patient volume. As hospital systems expand, private practitioners must remain nimble, while maintaining excellent service and outcomes, in order to stay ahead.

New graduate advanced practice providers (APPs) who accept jobs within the hematology-oncology field face many challenges when beginning their careers. Specific challenges include a lack of specialty-specific training, expedited orientation periods, and a large patient volume. These challenges can lead to dissatisfaction within the role, unsafe patient care, and ultimately costly job turnover. In order to better prepare APPs for the specialty workforce, the hematology-oncology fellowship program at Levine Cancer Institute has worked to develop and cultivate a comprehensive curriculum to meet the many needs identified. The hematology-oncology APP fellowship program is a 12-month curriculum that includes both didactic as well as clinical requirements. The fellowship program provides guidance in a structured practice setting and has ultimately offered APPs the opportunity to successfully transition into their specialty care role.

The relationship between the severe trauma patient volume and outcomes is still being debated. The aim of this study was to evaluate the relationship between severe trauma patient volume, hospital mortality, and door-to-definitive treatment time. This was a retrospective cohort study that used recorded data from the Japan Trauma Data Bank. We included severe trauma patients who had an Injury Severity Score greater than 16. Hospitals were categorized according to their annual severe trauma patient volume: low volume, 1–49 (reference), medium volume, 50–99, and high volume, ≥ 100]. The association of volume categories with in-hospital mortality was evaluated by use of a mixed-effects model adjusted for patient demographics and trauma severity. Additionally, the association of volume categories with in-hospital mortality among subgroups and with door-to-definitive treatment time were also evaluated. A total of 74,957 severe trauma patients from 213 hospitals were analyzed. In-hospital mortality was 15.7%, 15.2%, and 12.8% in the low volume, medium volume, and high volume groups, respectively. High volume was associated with reduced in-hospital mortality compared to low volume (odds ratio = 0.757, 95% confidence interval = 0.626–0.916). However, medium volume was not associated with reduced in-hospital mortality. Among subgroups, high volume was associated with reduced in-hospital mortality only in the probability of survival ≥ 0.5. Door-to-definitive treatment time was decreased in high volume, however, high volume was not associated with reduced in-hospital mortality among the patients who underwent definitive treatment and the patients whose ps

17 USC 105 interim-entered record; under temporary embargo. The regionalization of care for ST elevation myocardial infarction (STEMI) may unintentionally concentrate patients with non-ST elevation myocardial infarction (NSTEMI) into percutaneous coronary intervention (PCI) capable hospitals. This could lead to benefits such as increased access to PCI-capable hospitals, but could cause harms such as crowding in some hospitals with decreased patient volume and revenue in others. We set out to assess whether STEMI regionalization programs concentrated patients with NSTEMI at STEMI-receiving hospitals. U.S. Government affiliation is unstated in article text.

Background American College of Surgeons level I trauma center verification requires an active research program. This study investigated differences in the research programs of academic and non-academic trauma centers. Methods A 28-question survey was administered to ACS-verified level I trauma centers in 11/12/2020–1/7/2021. The survey included questions on center characteristics (patient volume, staff size), peer-reviewed publications, staff and resources dedicated to research, and funding sources. Results The survey had a 31% response rate: 137 invitations were successfully delivered via email, and 42 centers completed at least part of the survey. Responding level I trauma centers included 36 (86%) self-identified academic and 6 (14%) self-identified non-academic centers. Academic and non-academic centers reported similar annual trauma patient volume (2190 vs. 2450), number of beds (545 vs. 440), and years of ACS verification (20 vs. 14), respectively. Academic centers had more full-time trauma surgeons (median 8 vs 6 for non-academic centers) and general surgery residents (median 30 vs 7) than non-academic centers. Non-academic centers more frequently ranked trauma surgery (100% vs. 36% academic), basic science (50% vs. 6% academic), neurosurgery (50% vs. 14% academic), and nursing (33% vs. 0% academic) in the top three types of studies conducted. Academic centers were more likely to report non-profit status (86% academic, 50% non-academic) and utilized research funding from external governmental or non-profit grants more often (76% vs 17%). Conclusions Survey results suggest that academic centers may have more physician, resident, and financial resources available to dedicate to trauma research, which may make fulfillment of ACS level I research requirements easier. Structural and institutional changes at non-academic centers, such as expansion of general surgery resident programs and increased pursuit of external grant funding, may help ensure that academic and non-academic sites are equally equipped to fulfill ACS research criteria.

Objective We sought to assess the effect of National Football League (NFL) games played by a regional sports team, the New England Patriots, on emergency department (ED) patient volume. Methods We conducted a multicenter, retrospective chart review at the following 3 tertiary centers in New England from 2012 to 2019: Beth Israel Deaconess Medical Center, Boston, MA; Dartmouth Hitchcock Medical Center, Lebanon, NH; and Maine Medical Center, Portland, ME. Results Within the NFL season, we observed a 2.6% overall decrease (−10.4 patients) in average total daily volume across the study sites on Sundays when Patriots games were played compared with Sundays when games were not played (P = 0.07; 95% confidence interval [CI], −22.37 to 1.62). We observed a 4.3% reduction (−19.0 patients) in average total daily volume across the study sites on Mondays during which Patriots games were played compared with Mondays without games (P = 0.15; 95% CI, −43.51 to 5.47). Subanalyses on the 5‐hour period corresponding with each Patriots game showed reductions in mean patient volume per hour. Although our primary and subanalyses showed reductions in patient volume during Patriots games, these results were not statistically significant. Conclusions Our data support prior studies that showed a minimal impact of major sporting events on ED patient volume at tertiary centers. These results add to the limited data on this topic and can inform administrators whether staffing adjustments are necessary during similar types of sporting events.

COVID‐19 continues to affect the delivery of healthcare services, as practices across North America gradually re‐open with new safety measures and practice guidelines. Specifically in dermatology, clinical care is delivered in close physician‐patient proximity through physical examination and the use of additional diagnostic and therapeutic procedures. We designed a 10‐question survey to better understand how COVID‐19 has impacted the delivery of care in North American dermatology practices. Survey questions explored themes including changes in patient volumes, the use of virtual visits/teledermatology, the frequency of aesthetic and surgical procedures, and other related topics. We invited 102 board‐certified dermatologists working in a variety of medical, aesthetic, surgical, and mixed practices, to participate in our survey hosted through Qualtrics XM. These dermatologists were selected based on their geographic location and our ability to access their contact information. Each dermatologist received an individualized e‐mail and survey link; however, all survey responses were anonymized. In 2.5 weeks after survey invitations were sent, the survey was viewed and completed by 71 and 54 dermatologists, respectively. The second wave of e‐mails was sent to the remaining 48 dermatologists who had not yet completed the survey, after which 15 participants both viewed and completed the survey. In total, 69 responses were recorded with an overall response rate of 67.6%. We report decreased patient volume capacity, fewer aesthetic and surgical procedures, and an increase in the use of virtual medicine among board‐certified North American dermatologists. However, this represents a reflection on perspectives at a single time point in a rapidly evolving situation. Understanding the full scope of the impact that COVID‐19 continues to have on dermatologic care is paramount to effectively serve our patients.

Objectives: Emergency departments (ED) across the United States face challenges related to patient volume, available capacity, and patient throughput. Patient satisfaction is adversely affected by crowding and lengthy boarding times. This study aimed to determine whether the implementation of a dedicated nursing hold team (NHT) would improve patient satisfaction scores for admitted patients discharged directly from the ED. Methods: This was a retrospective, observational study with a pre-/post-test design. All admitted adult patients who returned a Press Ganey (PG) survey were included in the study. There were two twelve-month study periods before and after implementing an ED NHT. The primary outcome was the percentage of patients who gave top box scores for all questions in the Nursing Communication Domain. Results: During the pre-implementation period, 108 patients (59%) gave an overall top box rating for the Nursing Communication Domain versus the post-implementation period, where 99 patients (66%) provided a top box rating (OR 1.375, p = 0.16). There was a trend toward increased satisfaction for individual categories. However, these differences were not statistically significant. Conclusions: Implementing a dedicated NHT showed an increase in the overall top box PG Nursing Communication Domain score and several of the individual domain questions. Future studies should examine other potential benefits from a dedicated NHT, such as the rate of adverse events and medication delays.

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

Background To evaluate the impact of the COVID-19 outbreak on patient management at an Otolaryngology Head and Neck Surgery Department at a tertiary care center in Southeast Asia. This is a retrospective review. Patient load and diagnosis at the Outpatient Division of the Otolaryngology Head and Neck Surgery Department were reviewed at the height of the initial wave of the COVID-19 pandemic. Patient-specific data was then compared during the same timeframe one year prior. Patients were then grouped into an additional subspecialty subgroup based upon their diagnosis. Descriptive statistics were analyzed. Results A total of 819 cases were identified in 2019 during the study period. At the peak of the first wave, cases fell to 483, constituting a 41% decrease between the years (p value = 0.083). The largest decrease was in Otology cases with a drop by 53% (p value = 0.047), with the smallest decrease noted in General cases. Laryngology visits overall showed an increase in cases by 41.7%. Moreover, new visits decreased by 35.5%, with the largest decrease in new Laryngology visits and new Head and Neck Oncology cases. New visits for general issues had the smallest drop in patients, decreasing by only 21% (p value = 0.006) Conclusions The COVID-19 pandemic caused a significant decrease in overall cases in the Otolaryngology Head and Neck Surgery outpatient department. Thus, in anticipation of future outbreaks, interventions may be tailored according to these trends.

Making referrals to another specialty is an underemphasised skill in the undergraduate medical curriculum. As a result, many new foundation doctors find themselves ill-equipped to make effective referrals to other specialties as part of their day-to-day responsibilities. This can often be frustrating to the foundation doctor, the specialist and contribute to critical delays in patient care. Surgical registrars are required to triage patients (for urgent review or even to take to theatre) often under time and high patient volume pressures. As such, it is imperative for foundation doctors to make referrals as efficiently as possible to facilitate surgical specialty decision making and, ultimately, to expedite medical care to patients. In this article, we describe 10 tips for the foundation doctor in making inpatient referrals to surgical specialties.

Introduction: Opioid use disorder (OUD) affects 2 million Americans, yet many patients do not receive treatment. Lack of team-based care is a common barrier for office-based opioid treatment (OBOT). In 2015, we started OBOT in a family medicine practice. Based on our experiences, we developed a financial model for hiring a team member to provide nonbillable OBOT services through revenue from increased patient volume. Methods: We completed a retrospective chart review from July 2015 to December 2016 to determine the average difference in medical visits per patient per month pre-OBOT versus post-OBOT. Secondary outcomes were the percentage of visits coded as a Level 3, Level 4, and Level 5, and the percentage of patients with Medicaid, private insurance, or self pay. With this information, we extrapolated to build a financial model to hire a team member to support OBOT. Results: Twenty-three patients received OBOT during the study period. There was a net increase of 1.93 visits per patient per month (P Conclusions: In a fee-for-service model, the revenue generated from increased medical visits can offset the cost of hiring a team member to support nonbillable OBOT services.

Declining case volumes on trauma rotations and early specialization of traditional surgical rotations have limited the service lines on which general surgery residents can obtain critical operative and management experience. Meanwhile, a significant portion of residents have no exposure to a burn rotation during their training. A burn rotation may address both of these issues in a meaningful way. Surgical case volumes and burn ICU patient volume were queried for an urban regional verified burn referral center. General surgery program resident case logs were queried for procedures performed during a burn rotation during that same time period. Over a four-year time period, three burn surgeons performed a total of 2374 procedures on burn and wound service patients. In the burn ICU over that same time period, 419 individual critical care patients were managed. Twenty-seven general surgery program residents logged 632 major operations and 67 critical care patients; more than 50 per cent of cases performed were not captured by the Accreditation Council for Graduate Medical Education case log system. A high volume burn service can adequately provide surgical and critical care exposure to junior surgical residents. Accreditation Council for Graduate Medical Education surgical case logs may not fully represent the full scope of exposure sustained on a high-volume burn service.

Introduction Warfarin dosing algorithms have proven beneficial in increasing time within therapeutic range (TTR) and decreasing adverse events associated with out-of-range international normalized ratios (INRs). Despite widespread availability, providers' utilization and perceptions of warfarin algorithms in real-world practice are unclear. Identifying perceptions and barriers to algorithm use may help attempts to improve warfarin therapy management. Methods Anticoagulation providers' utilization and perceptions of warfarin dosing algorithms were assessed via a nationwide electronic survey. Results Of the 246 providers who completed the survey, 82% were pharmacists, and 69% had over five years' experience dosing warfarin. Warfarin dosing algorithms were deemed beneficial by 84% of respondents and 72% currently use a warfarin dosing algorithm in their practice at least occasionally. Pharmacists were least likely of anticoagulation providers to use algorithms, although this was not statistically significant (p = 0.12). Algorithm utilization also decreased as years of warfarin dosing experience increased, with the highest rate of usage noted in the first year of dosing warfarin. The most common reason providers gave for discontinuing algorithm use was that they no longer felt it was needed. In this study, clinic patient volume did not appear to be associated with algorithm utilization. Conclusion Warfarin dosing algorithms are frequently used among anticoagulation providers, especially those new to dosing warfarin, but use is frequently not sustained over the long-term. Education on the continued benefits of warfarin dosing algorithms could increase long-term utilization, potentially improving patient outcomes.

Background: Global health emergencies, such as from diseases like dengue fever, can lead to rapid surges in visits to emergency departments. The objective of our study was to evaluate the impact of dengue on factors that could impact emergency department flow, including patient volume and staffing, on Indian emergency departments. Methods: This was a prospective cohort study of Indian emergency providers. Respondents were queried via online survey about a number of domains including practice environment, use of rapid testing, changes in ED volume and ED staffing adjustments occurring during dengue season. Data was analyzed using multivariate analysis. Results: We had a total of 210 respondents to our online survey. Less than half of respondents reported that their institutions used rapid point of care testing. When asked how dengue impacted ED flow, the most common response was that dengue increased the total number of ED visits (84%). Despite this increase, only about 32% of respondents reported that their institutions increased hospital staffing. In multivariate analysis, respondents at hospitals that experienced ED visit surges over 40% of baseline were more likely to also report that their institutions also increased staffing during this time (OR 3.28, 95% CI 1.44–7.46). Conclusions: Our study shows that despite increases in visits during dengue season, ED providers noted that their EDs did not respond with staffing increases. More research is needed to better understand how emergency departments can adjust to dengue to provide optimal care for patients in India. Keywords: Dengue, Surge

Topical chlormethine yields high response rates in mycosis fungoides cutaneous T-cell lymphoma with early discontinuation often attributed to skin reactions. We evaluated over 4,000 patients and found an association of clinician case volume with treatment duration and early discontinuation of chlormethine gel. The minority of clinicians with high patient volume markedly outperformed clinicians with only few patients on both outcome parameters, yet case volume as low as five patients seemed to mark a threshold for avoiding early discontinuation of treatment regimen.

Introduction: Daily patient volume in emergency departments (ED) varies considerably between days and sites. Although studies have attempted to define “high-volume” days, no standard definition exists. Furthermore, it is not clear whether the frequency of high-volume days, by any definition, is related to the size of an ED. We aimed to determine the correlation between ED size and the frequency of high-volume days for various volume thresholds, and to develop a measure to identify high-volume days. Methods: We queried retrospective patient arrival data including 1,682,374 patient visits from 32 EDs in 12 states between July 1, 2018–June 30, 2019 and developed linear regression models to determine the correlation between ED size and volume variability. In addition, we performed a regression analysis and applied the Pearson correlation test to investigate the significance of median daily volumes with respect to the percent of days that crossed four volume thresholds ranging from 5–20% (in 5% increments) greater than each site’s median daily volume. Results: We found a strong negative correlation between ED median daily volume and volume variability (R2 = 81.0%; P < 0.0001). In addition, the four regression models for the percent of days exceeding specified thresholds greater than their daily median volumes had R2 values of 49.4%, 61.2%, 70.0%, and 71.8%, respectively, all with P < 0.0001. Conclusion: We sought to determine whether smaller EDs experience high-volume days more frequently than larger EDs. We found that high-volume days, when defined as days with a count of arrivals at or above certain median-based thresholds, are significantly more likely to occur in lower-volume EDs than in higher-volume EDs. To the extent that EDs allocate resources and plan to staff based on median volumes, these results suggest that smaller EDs are more likely to experience unpredictable, volume-based staffing challenges and operational costs. Given the lack of a standard measure to define a high-volume day in an ED, we recommend 10% above the median daily volume as a metric, for its relevance, generalizability across a broad range of EDs, and computational simplicity.

This cross-sectional study uses data from the National Cancer Database to investigate trends in patient volume by hospital type and the association of patient volume with time to treatment initiation for patients with cancer by hospital type., Key Points Question Is the number of patients with cancer who are treated at referral centers increasing, and are more rapid increases in patient volume associated with treatment delays? Findings In this cross-sectional study of 4 218 577 patients treated for an incident cancer at 1351 hospitals from 2007 to 2016, patient volume increased more rapidly at National Cancer Institute and academic centers than at community hospitals, but this was not associated with clinically meaningful increases in time to treatment initiation. Meaning Faster patient volume growth at referral centers was not associated with clinically meaningful cancer treatment delays., Importance Increasing demand for cancer care may be outpacing the capacity of hospitals to provide timely treatment, particularly at referral centers such as National Cancer Institute (NCI)–designated and academic centers. Whether the rate of patient volume growth has strained hospital capacity to provide timely treatment is unknown. Objective To evaluate trends in patient volume by hospital type and the association between a hospital’s annual patient volume growth and time to treatment initiation (TTI) for patients with cancer. Design, Setting, and Participants This retrospective, hospital-level, cross-sectional study used longitudinal data from the National Cancer Database from January 1, 2007, to December 31, 2016. Adult patients older than 40 years who had received a diagnosis of 1 of the 10 most common incident cancers and initiated their treatment at a Commission on Cancer–accredited hospital were included. Data were analyzed between December 19, 2019, and March 27, 2020. Exposures The mean annual rate of patient volume growth at a hospital. Main Outcomes and Measures The main outcome was TTI, defined as the number of days between diagnosis and the first cancer treatment. The association between a hospital’s mean annual rate of patient volume growth and TTI was assessed using a linear mixed-effects model containing a patient volume × time interaction. The mean annual change in TTI over the study period by hospital type was estimated by including a hospital type × time interaction term. Results The study sample included 4 218 577 patients (mean [SD] age, 65.0 [11.4] years; 56.6% women) treated at 1351 hospitals. From 2007 to 2016, patient volume increased 40% at NCI centers, 25% at academic centers, and 8% at community hospitals. In 2007, the mean TTI was longer at NCI and academic centers than at community hospitals (NCI: 50 days [95% CI, 48-52 days]; academic: 43 days [95% CI, 42-44 days]; community: 37 days [95% CI, 36-37 days]); however, the mean annual increase in TTI was greater at community hospitals (0.56 days; 95% CI, 0.49-0.62 days) than at NCI centers (−0.73 days; 95% CI, −0.95 to −0.51 days) and academic centers (0.14 days; 95% CI, 0.03-0.26 days). An annual volume growth rate of 100 patients, a level observed at less than 1% of hospitals, was associated with a mean increase in TTI of 0.24 days (95% CI, 0.18-0.29 days). Conclusions and Relevance In this cross-sectional study, from 2007 to 2016, across the studied cancer types, patients increasingly initiated their cancer treatment at NCI and academic centers. Although increases in patient volume at these centers outpaced that at community hospitals, faster growth was not associated with clinically meaningful treatment delays.

ObjectiveStudies describe COVID-19 patient characteristics and outcomes across populations, but reports of variation across healthcare facilities are lacking. The objectives were to examine differences in COVID-19 patient volume and mortality across facilities, and understand whether facility variation in mortality was due primarily to differences in patient versus facility characteristics.DesignObservational cohort study with multilevel mixed effects logistic regression modelling.SettingThe Veterans Health Administration (VA) is the largest healthcare system in the USA.ParticipantsPatients with COVID-19.Main outcomeAll-cause mortality within 45 days after COVID-19 testing (March–May, follow-up through 16 July 2020).ResultsAmong 13 510 patients with COVID-19, 3942 (29.2%) were admitted (2266/3942 (57.5%) ward; 1676/3942 (42.5%) intensive care unit (ICU)) and 679/3942 (17.2%) received mechanical ventilation. Marked heterogeneity was observed across facilities in median age (range: 34.3–83.9 years; facility mean: 64.7, SD 7.2 years); patient volume (range: 1–737 at 160 facilities; facility median: 48.5, IQR 14–105.5); hospital admissions (range: 1–286 at 133 facilities; facility median: 11, IQR 1–26.5); ICU caseload (range: 1–85 at 115 facilities; facility median: 4, IQR 0–12); and mechanical ventilation (range: 1–53 at 90 facilities; facility median: 1, IQR 0–5). Heterogeneity was also observed in facility mortality for all patients with COVID-19 (range: 0%–29.7%; facility median: 8.9%, IQR 2.4%–13.7%); inpatients (range: 0%–100%; facility median: 18.0%, IQR 5.6%–28.6%); ICU patients (range: 0%–100%; facility median: 28.6%, IQR 14.3%–50.0%); and mechanical ventilator patients (range: 0%–100%; facility median: 52.7%, IQR 33.3%–80.6%). The majority of variation in facility mortality was attributable to differences in patient characteristics (eg, age).ConclusionsMarked heterogeneity in COVID-19 patient volume, characteristics and mortality were observed across VA facilities nationwide. Differences in patient characteristics accounted for the majority of explained variation in mortality across sites. Variation in unadjusted COVID-19 mortality across facilities or nations should be considered with caution.

Purpose To examine possible changes in the emergency patient volume and reasons for presentation to an oral and maxillofacial surgery department during the coronavirus disease 2019 (COVID-19) pandemic and the resulting contact prohibitions. We hypothesized that the pandemic would lead to fewer patients presenting with emergent conditions. Methods A total of 939 patients, who presented to the Department for Oral and Maxillofacial Surgery of Hannover Medical School during the first 4 weeks of contact prohibitions in Germany, starting from March 23, 2020 until April 19, 2020, and in comparable periods were examined. The number of patients, reason for presentation, and required treatments were documented and compared to the years 2018 and 2019. Special attention was paid to the changes in trauma cases. Results We found that the number of patients in 2020 was significantly lower (p(2019) < 0.001, p(2018) < 0.01), but sex and age distributions were comparable to those in the previous years. Both the absolute and relative frequencies of dental diagnoses were significantly lower in 2020 (p(2019) < 0.001, p(2018) < 0.001), while the proportion of patients who presented with trauma was significantly higher (p(2019) < 0.001, p(2018) < 0.001). A significant decrease in patient number to the hospital, despite private practices being closed, was presumably due to patients' infection-related concerns. Trauma cases were more frequent in private settings, and traumatic events under the influence of alcohol were frequent. The circumstances and not the absolute number of trauma events had changed. Conclusion The results of this study suggest that the COVID-19 pandemic has important effects on the use of emergency services concerning oral and maxillofacial surgery in Germany.

Introduction The relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce. Methods We analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns. Results 2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients. Conclusions Despite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.

Introduction Mean daily temperatures in Canada rose 1.7°C between 1948 and 2016, and the frequency, severity, and duration of extreme heat events has increased. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). This retrospective analysis assessed the impact of temperature and humidex on ED volume and length of stay (LOS). Methods LOS is an indicator of ED overcrowding and system performance. Using daily maximum temperatures and humidex values, this study investigated the impact of mean 3-d temperatures and humidex preceding ED presentation on the median and maximum ED LOS and patient volume in 2 community hospitals in Montreal, Quebec, during the summer months of 2016 to 2018. Data were analyzed with 1-way analysis of variance with post hoc Fisher least significant difference tests and Spearman correlation tests. Results The mean maximum temperature and humidex were 26.1°C and 30.4°C, respectively (n=276 d). Mean 3-d temperatures ≥30°C were associated with higher daily ED volumes in both hospitals (138 vs 121, P=0.002 and 132 vs 125, P=0.03) and with increased median LOS at 1 hospital (8.9 vs 7.6 h, P=0.03). Mean 3-d humidex ≥35 was associated with higher daily ED volumes at both hospitals as well (136 vs 123, P=0.01 and 133 vs 125, P=0.009) with an increased median LOS at 1 hospital (8.6 vs 6.9 h, P=0.0001) with humidex values of 25 to 29.9°C. Conclusions Heat events were associated with increased ED presentations and LOS. This study suggests that a warming climate can impede emergency service provision by increasing the demand for and delaying timely care.

Background Communication in emergency departments (ED) in India is complicated by the country’s immense language diversity. Prior research has revealed challenges in language and communication as barriers to care. Our objective was to quantify language diversity among clinicians in Indian EDs and better understand issues related to clinician-clinician and clinician-patient communication. Methodology A cross-sectional survey of ED clinicians was conducted. Survey participants were recruited in-person and through email at six partner sites in India. ANOVA and binary logistic regression were used for subgroup analysis. Semi-structured interviews were conducted with ED clinicians. Interview data was analyzed using the rapid assessment process to determine predominant themes. Results 106 clinicians completed the survey. On average, clinicians spoke 3.75 languages. Seventy-one percent used a non-English language to speak to fellow clinicians most of the time, and 53% reported at least one critical incident over the last year where poor communication played a part. Interviews revealed challenges including low health literacy, high patient volume, and workplace hierarchy. Conclusions This study is the first to document the impact of language diversity and communication barriers in Indian EDs. The results highlight the need for effective strategies to improve communication between the multiple languages spoken by clinicians and patients.

Background Variations in hospitals’ care demand relies not only on the patient volume but also on the disease severity. Understanding both daily severity and patient volume in hospitals could help to identify hospital pressure zones to improve hospital-capacity planning and policy-making. Objective This longitudinal study explored daily care demand dynamics in Swiss general hospitals for 3 measures: (1) capacity utilization, (2) patient turnover, and (3) patient clinical complexity level. Methods A retrospective population-based analysis was conducted with 1 year of routine data of 1.2 million inpatients from 102 Swiss general hospitals. Capacity utilization was measured as a percentage of the daily maximum number of inpatients. Patient turnover was measured as a percentage of the daily sum of admissions and discharges per hospital. Patient clinical complexity level was measured as the average daily patient disease severity per hospital from the clinical complexity algorithm. Results There was a pronounced variability of care demand in Swiss general hospitals. Among hospitals, the average daily capacity utilization ranged from 57.8% (95% CI 57.3-58.4) to 87.7% (95% CI 87.3-88.0), patient turnover ranged from 22.5% (95% CI 22.1-22.8) to 34.5% (95% CI 34.3-34.7), and the mean patient clinical complexity level ranged from 1.26 (95% CI 1.25-1.27) to 2.06 (95% CI 2.05-2.07). Moreover, both within and between hospitals, all 3 measures varied distinctly between days of the year, between days of the week, between weekdays and weekends, and between seasons. Conclusions While admissions and discharges drive capacity utilization and patient turnover variation, disease severity of each patient drives patient clinical complexity level. Monitoring—and, if possible, anticipating—daily care demand fluctuations is key to managing hospital pressure zones. This study provides a pathway for identifying patients’ daily exposure to strained hospital systems for a time-varying causal model.

Disease site leadership is predicated on knowledge, clinical expertise, and networking. Developing an expertise may require months to years to gain the necessary experience, and the largest gains can be expected in topics of high personal interest, areas where there is a large patient volume, or other institutional foci for which there is support or dedicated resources. Working with colleagues to educate, collaborate, or develop new areas of growth can provide personal satisfaction and expertise in a disease topic and contributes to specialized expertise. Harnessing opportunities through access to key stakeholders may enhance success and recognition. Continuing to connect with colleagues throughout and outside of the institution can lead to continued evolution and fulfillment.