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Purpose Internationally, healthcare systems are moving towards delivering care in an integrated manner which advocates a multi-disciplinary approach to decision making. Such an approach is formally encouraged in the management of Atrial Fibrillation patients through the European Society of Cardiology guidelines. Since the emergence of new oral anticoagulants switching between oral anticoagulants (OACs) has become prevalent. This case study considers the role of multi-disciplinary decision making, given the complex nature of the agents. The purpose of this paper is to explore Irish General Practitioners' (GPs) experience of switching between all OACs for Arial Fibrillation (AF) patients; prevalence of multi-disciplinary decision making in OAC switching decisions and seeks to determine the GP characteristics that appear to influence the likelihood of multi-disciplinary decision making. Design/methodology/approach A probit model is used to determine the factors influencing multi-disciplinary decision making and a multinomial logit is used to examine the factors influencing who is involved in the multi-disciplinary decisions. Findings Results reveal that while some multi-disciplinary decision-making is occurring (64 per cent), it is not standard practice despite international guidelines on integrated care. Moreover, there is a lack of patient participation in the decision-making process. Female GPs and GPs who have initiated prescriptions for OACs are more likely to engage in multi-disciplinary decision-making surrounding switching OACs amongst AF patients. GPs with training practices were less likely to engage with cardiac consultants and those in urban areas were more likely to engage with other (non-cardiac) consultants. Originality/value For optimal decision making under uncertainty multi-disciplinary decision-making is needed to make a more informed judgement and to improve treatment decisions and reduce the opportunity cost of making the wrong decision.

Background: The Irish government has committed to expand midwifery-led care alongside consultant-led care nationally, although very little is known about the potential net benefits of this reconfiguration., Objectives: To formally compare the costs and benefits of the major models of care in Ireland, with a view to informing priority setting using the contingent valuation technique and cost-benefit analysis., Methods: A marginal payment scale willingness-to-pay question was adopted from an ex ante perspective. 450 pregnant women were invited to participate in the study. Cost estimates were collected primarily, describing the average cost of a package of care. Net benefit estimates were calculated over a 1-year cycle using a third-party payer perspective., Results: To avoid midwifery-led care, women were willing to pay €821.13 (95% CI 761.66-1150.41); to avoid consultant-led care, women were willing to pay €795.06 (95% CI 695.51-921.15). The average cost of a package of consultant- and midwifery-led care was €1,762.12 (95% CI 1496.73-2027.51) and €1018.47 (95% CI 916.61-1120.33), respectively. Midwifery-led care ranked as the best use of resources, generating a net benefit of €1491.22 (95% CI 989.35-1991.93), compared with €123.23 (95% CI -376.58 to 621.42) for consultant-led care., Conclusions: While both models of care are cost-beneficial, the decision to provide both alternatives may be constrained by resource issues. If only one alternative can be implemented then midwifery-led care should be undertaken for low-risk women, leaving consultant-led care for high-risk women. However, pursuing one alternative contradicts a key objective of government policy, which seeks to improve maternal choice. Ideally, multiple alternatives should be pursued.

Background: Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes., Methods: Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures., Results: 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day., Conclusion: In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research., Competing Interests: Conflict of interest Nothing to declare

Federally qualified health centers (FQHCs) provide low- or no-cost primary care to medically underserved populations such as homeless or low-income people, migrant workers, and members of marginalized cultural groups. Occupational therapy services have the potential to help improve the health and functioning of FQHC patients. Using a FQHC serving American Indian/Alaska Native populations as a case example, we describe how occupational therapy is well suited to help meet the needs of medically underserved populations. We then examine options for integrating occupational therapy into this unique primary care setting, discuss related administrative and policy considerations, and propose possible solutions to identified barriers., (Copyright © 2017 by the American Occupational Therapy Association, Inc.)

Objective: To assess the comparative cost effectiveness of day care over inpatient management of nausea and vomiting of pregnancy (NVP)., Study Design: A cost utility analysis was performed using a decision analytical model in which a Markov model was constructed. The Markov model was primarily populated with data from a recently published randomised controlled trial. Which included pregnant women presenting to Cork University Maternity Hospital, a tertiary referral maternity hospital, seeking treatment for NVP. Costs and outcomes were estimated from the perspective of the Irish health service (HSE) and patients. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was also performed. A Bayesian Value of Information analysis was used to estimate the value of collecting additional information., Results: When both the healthcare provider and patient's perspective was considered, day care management of NVP remained less costly (mean €985; 95% C.I. 705-1456 vs. €3837 (2124-8466)) and more effective (9.42; 4.19-12.25 vs. 9.49; 4.32-12.39 quality adjusted life years) compared with inpatient management. The Cost Effectiveness Acceptability Curve indicates the probability that day care management is 70% more cost effective compared to inpatient management at a ceiling ratio of €45,000 per QALY, indicating little decision uncertainty. The Bayesian Value of Information analysis indicates there is value in collecting further information; the Expected Value of Perfect Information (EVPI) is estimated to be €5.4 million., Conclusion: Day care management of NVP is cost effective compared to inpatient management., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine day care treatment of nausea and vomiting of pregnancy compared with the traditional inpatient management of this condition., Methods: We conducted an open-label, single-center, randomized controlled trial to examine the differences between day care and inpatient management of pregnant women with nausea and vomiting of pregnancy. Primary outcome was total number of inpatient nights related to nausea and vomiting of pregnancy., Results: Ninety-eight women were randomized to initial day care management (n=42) or inpatient management (n=56). Results are calculated from the time of randomization until resolution of nausea and vomiting of pregnancy. Women randomized to inpatient care experienced a median (interquartile range) of 2 (1-4) inpatient days compared with 0 (0-2) inpatient days for women randomized to day care (P<.001). Women randomized to initial treatment as an inpatient had significantly more median total number of inpatient admissions (one [1-2] compared with zero [0-1] admissions; P<.001) compared with women randomized to day care. No significant differences were observed in day care visits (median [interquartile range] one [1-4] compared with two [1-4]; P=.30). Women randomized to inpatient care were as satisfied with their care as those randomized to day care (median [interquartile range]: 67 [57-69] compared with 63 [58-71] Client Satisfaction Questionnaire score; P=.7)., Conclusion: Day care treatment of nausea and vomiting of pregnancy reduced hospital inpatient stay and was acceptable to patients., Clinical Trial Registration: ISRCTN Register, http://www.isrctn.org, ISRCTN05023126., Level of Evidence: : I.

Some studies suggest lesbian, gay, and bisexual (LGB) teens are at higher risk than peers for violence at home, in school, and in the community. That can bring them into the child welfare system or services for runaway and homeless teens. This study compared self-reported experiences of sexual and physical abuse based on sexual orientation and gender in seven population-based surveys of youth. The authors used c2 and age-adjusted odds of abuse to compare bisexual to heterosexual, mostly heterosexual, and gay and lesbian students. They also provide case studies to illustrate the experiences of such youth.

In a previous study assessing tadalafil for the treatment of erectile dysfunction (ED), tadalafil 20 mg was shown to improve erectile function for up to 36 hours vs placebo. This study sought to demonstrate the effectiveness of both 10- and 20-mg tadalafil vs placebo at 2 prespecified assigned times of 24 and 36 hours postdosing. This double-blind, placebo-controlled, parallel-group study randomized 483 men with ED into 6 groups according to a combination of treatment (placebo, tadalafil 10 or 20 mg) and assigned time (24 or 36 hours) for intercourse attempts. Patients were stratified by baseline ED severity based on Erectile Function Domain scores. The study had 4 phases: a 4-week run-in (no ED medication taken); a 2- to 4-week equilibration (dosing as needed); a 4- to 6-week assessment; and a 6-month open-label extension. During the assessment phase, men took a total of 4 doses of study medication, each dose separated by more than or equal to 7 days. Efficacy was measured as the mean per-patient percentage of successful intercourse attempts (Sexual Encounter Profile Diary Question 3: SEP3) during the assessment phase. Men taking either 10- or 20-mg tadalafil had a significant increase in SEP3 from baseline scores vs placebo at both 24 hours (P = .038 and <.001 for 10 and 20 mg, respectively) and 36 hours (P < .001 for both doses) postdose. The mean per-patient percentages of successful intercourse attempts for the 24-hour time point were 41.8%, 55.8%, and 67.3% for placebo and tadalafil 10 and 20 mg, respectively; for the 36-hour time point, the mean per-patient percentages were 32.8%, 56.2%, and 61.9% for placebo and tadalafil 10 and 20 mg, respectively. The most common treatment-emergent adverse events were headache, back pain, dyspepsia, and nasopharyngitis. Both 10- and 20-mg tadalafil improved erectile function for up to 36 hours postdosing in men with ED of varied severity.