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Supplemental Digital Content is available in the text., Background: Many health plans have outreach programs aimed at appropriately screening, evaluating, and treating women experiencing fragility fractures; however, few programs exist for men. Objective: The objective of this study was to develop, implement, and evaluate an osteoporosis outreach program for men with a recent fragility fracture and their physicians. Research Design and Subjects: A total of 10,934 male patients enrolled in a Medicare Advantage with Prescription Drug Plan with a recent fragility fracture were randomized to a program or control group. Patients and their physicians received letters followed by phone calls on osteoporosis and the importance of screening and treatment. The evaluation compared bone mineral density (BMD) test utilization and osteoporosis medication treatment (OPT) among patients who received the outreach versus no outreach at 12 months. The effect of the program was estimated through univariate and multivariable logistic regressions. Results: The program had a significant impact on BMD evaluation and OPT initiation. At 12 months, 10.7% of participants and 4.9% of nonparticipants received a BMD evaluation. The odds ratio (OR) (95% confidence interval) was 2.31 (1.94, 2.76), and the number needed to outreach to receive a BMD test was 18. OPT was initiated in 4.0% of participants and 2.5% of nonparticipants. The OR (95% confidence interval) of receiving OPT was 1.60 (1.24, 2.07), and the number needed to outreach was 69. Adjusted ORs were similar in magnitude and significance. Conclusion: The program was highly effective by more than doubling the rate of BMD evaluation; however, more intensive interventions may yield an even higher screening rate.

Background Patient engagement and patient-centered care are critical in optimally managing patients with end-stage renal disease (ESRD). Understanding patient preferences is a key element of patient-centered care and shared decision making. The objective of this study was to elicit patients’ preferences for the treatment of secondary hyperparathyroidism (SHPT) associated with ESRD using a discrete-choice experiment survey. Methods Clinical literature, nephrologist input, patient-education resources, and a patient focus group informed development of the survey instrument, which was qualitatively pretested before its administration to a broader sample of patients. The National Kidney Foundation invited individuals in the United States with ESRD who were undergoing hemodialysis to participate in the survey. Respondents chose among three hypothetical SHPT treatment alternatives (two medical alternatives and surgery) in each of a series of questions, which were defined by attributes of efficacy (effect on laboratory values and symptoms), safety, tolerability, mode of administration, and cost. The survey instrument included a best-worst scaling exercise to quantify the relative bother of the individual attributes of surgery. Random-parameters logit models were used to evaluate the conditional relative importance of the attributes. Results A total of 200 patients with ESRD completed the survey. The treatment attributes that were most important to the respondents were whether a treatment was a medication or surgery and out-of-pocket cost. Patients had statistically significant preferences for efficacy attributes related to symptom management and laboratory values, but placed less importance on the attributes related to mode of administration and side effects. The most bothersome attribute of surgery was the risk of surgical mortality. Conclusions Patients with ESRD and SHPT who are undergoing hemodialysis understand SHPT and have clear and measurable treatment preferences. These results may help inform clinicians about patients’ preferences regarding treatment options for a common complication of ESRD. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0665-8) contains supplementary material, which is available to authorized users.

Background Patient engagement in end-stage renal disease (ESRD) is expected to result in a more patient-centered approach to care that aligns with patients’ values, preferences, and goals for treatment. Nevertheless, no previous studies of which we are aware have evaluated patients’ benefit-risk preferences for the management of anemia associated with ESRD. The primary objective of this study was to quantify the tradeoffs patients are willing to make between cardiovascular risks associated with some anemia medicines and red blood cell (RBC) transfusions. A secondary objective was to quantify the importance of avoiding transfusion-related risks. Methods A survey instrument was developed from the clinical literature, clinician input, patient-education resources, and a patient focus group. The survey instrument was qualitatively pretested before its administration to a broader sample of patients. The National Kidney Foundation invited individuals in the United States to participate in the survey. In a discrete-choice experiment (DCE), respondents chose between two hypothetical anemia medications in a series of questions. Each medication was defined by symptom relief, frequency of transfusions, cardiovascular risk, mode of administration, and out-of-pocket cost. The survey also included a best-worst scaling (BWS) exercise to quantify the importance of avoiding attributes of blood transfusions. Results from the DCE were used to estimate relative importance and marginal willingness to pay. Results from the BWS were converted to relative importance weights. Results A total of 200 individuals completed the survey. Patients were willing to accept a 6% medication-related risk of heart attack to avoid having two RBC transfusions per month. Symptom relief and mode of administration were of moderate importance. The most important transfusion-related risk to avoid was transfusion-related lung injury. Conclusions Patients with ESRD and anemia have measurable treatment preferences and are willing to accept risks associated with anemia medications to avoid transfusions. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0664-9) contains supplementary material, which is available to authorized users.

Background: The goal of this study was to compare the performance of several database algorithms designed to identify red blood cell (RBC) Transfusion Related hospital Admissions (TRAs) in Veterans with end stage renal disease (ESRD).Methods: Hospitalizations in Veterans with ESRD and evidence of dialysis between 01/01/2008 and 12/31/2013 were screened for TRAs using a clinical algorithm (CA) and four variations of claims-based algorithms (CBA 1–4). Criteria were implemented to exclude patients with non-ESRD-related anemia (e.g., injury, surgery, bleeding, medications known to produce anemia). Diagnostic performance of each algorithm was delineated based on two clinical representations of a TRA: RBC transfusion required to treat ESRD-related anemia on admission regardless of the reason for admission (labeled as TRA) and hospitalization for the primary purpose of treating ESRD-related anemia (labeled TRA-Primary). The performance of all algorithms was determined by comparing each to a reference standard established by medical records review. Population-level estimates of classification agreement statistics were calculated for each algorithm using inverse probability weights and bootstrapping procedures. Due to the low prevalence of TRAs, the geometric mean was considered the primary measure of algorithm performance.Results: After application of exclusion criteria, the study consisted of 12,388 Veterans with 26,672 admissions. The CA had a geometric mean of 90.8% (95% Confidence Interval: 81.8, 95.6) and 94.7% (95% CI: 80.5, 98.7) for TRA and TRA-Primary, respectively. The geometric mean for the CBAs ranged from 60.3% (95% CI: 53.2, 66.9) to 91.8% (95% CI: 86.9, 95) for TRA, and from 80.7% (95% CI: 72.9, 86.7) to 96.7% (95% CI: 94.1, 98.2) for TRA-Primary. The adjusted proportions of admissions classified as TRAs was 3.2% (95% CI: 2.8, 3.8) and TRA-Primary was 1.3% (95% CI: 1.1, 1.7).Conclusions: The CA and select CBAs were able to identify TRAs and TRA-primary with high levels of accuracy and can be used to examine anemia management practices in ESRD patients.

ContextFor health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties.ObjectiveTo assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system.DesignCross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.Main outcome measuresPrimary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income.ResultsOf the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income.ConclusionIt is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.

Background Approximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services. Objectives To assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided. Design Cross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. Main outcome measures The proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate). Results More than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate. Discussion The low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed. Conclusion On the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

This article aims to test whether a workplace wellness program reduces health care cost for higher risk employees or employees with greater participation.The program effect on costs was estimated using a generalized linear model with a log-link function using a difference-in-difference framework with a propensity score matched sample of employees using claims and program data from a large US firm from 2003 to 2011.The program targeting higher risk employees did not yield cost savings. Employees participating in five or more sessions aimed at encouraging more healthful living had about $20 lower per member per month costs relative to matched comparisons (P = 0.002).Our results add to the growing evidence base that workplace wellness programs aimed at primary prevention do not reduce health care cost, with the exception of those employees who choose to participate more actively.

Objectives The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice. Methods As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented. Results In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be “extremely” or “very” helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Conclusions Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.

This dissertation, in a three paper format, examines three policy levers for improving health care value.

Aim To characterize the clinical context for the decision to order red blood cell (RBC) transfusions in dialysis patients. Materials and methods Retrospective review of medical records from three integrated health systems serving chronic dialysis patients. Subjects were randomly selected from all patients who received at least one transfusion between January 2009 and December 2013. Data abstracted included transfusion setting, prescribing clinician type, patient demographics and hemoglobin (Hb) concentration prior to transfusion, and cataloguing and prioritizing of clinical factors for their contribution to the decision to transfuse. Data from one system were stratified between transfusions before and after the 2011 dialysis payment reform and anemia drug label changes. Results Charts for 590 patients were reviewed. The primary reason for transfusion was low Hb (51%), medical conditions (22%), symptoms of anemia (18%), surgery-related (6%), and undetermined (3%). In 93% of cases, multiple factors were cited as contributors to the transfusion decision. Mean Hb prior to transfusion was 7.2 g/dL in patients where low Hb was the primary reason for transfusion (range: 4.0 - 9.9 g/dL). Conclusions The decision to transfuse dialysis patients is influenced by multiple patient factors and medical conditions, of which low Hb is the main contributor to this decision about half of the time. .

Purpose The goal of this study was to assess and compare the potential clinical and economic value of emerging bone-forming agents using the only currently available agent, teriparatide, as a reference case in patients at high, near-term (imminent, 1- to 2-year) risk of osteoporotic fractures, extending to a lifetime horizon with sequenced antiresorptive agents for maintenance treatment. Methods Analyses were performed by using a Markov cohort model accounting for time-specific fracture protection effects of bone-forming agents followed by antiresorptive treatment with denosumab. The alternative bone-forming agent profiles were defined by using assumptions regarding the onset and total magnitude of protection against fractures with teriparatide. The model cohort comprised 70-year-old female patients with T scores below –2.5 and a previous vertebral fracture. Outcomes included clinical fractures, direct costs, and quality-adjusted life years. The simulated treatment strategies were compared by calculating their incremental “value” (net monetary benefit). Findings Improvements in the onset and magnitude of fracture protection (vs the teriparatide reference case) produced a net monetary benefit of $17,000,000 per 10,000 treated patients during the (1.5-year) bone-forming agent treatment period and $80,000,000 over a lifetime horizon that included 3.5 years of maintenance treatment with denosumab. Implications Incorporating time-specific fracture effects in the Markov cohort model allowed for estimation of a range of cost savings, quality-adjusted life years gained, and clinical fractures avoided at different levels of fracture protection onset and magnitude. Results provide a first estimate of the potential “value” new bone-forming agents (romosozumab and abaloparatide) may confer relative to teriparatide.

e18298 Background: Febrile neutropenia (FN) is a key driver of morbidity and mortality in oncology patients receiving myelotoxic chemotherapy. Identification and prophylaxis per guidelines can result in a substantial reduction of FN risk and is a key oncology quality of care measure. This project evaluated the feasibility of using electronic medical records (EMR) to quantify FN rates and characterize patients at risk for FN. Methods: Search algorithm was used in EMR to identify patients initiating oncologic care between 1/1/2016 and 12/1/2017 at the Masonic Cancer Clinic, University of Minnesota—Fairview Health System, for a lymphoid, gastrointestinal, breast, female genital, or thoracic malignancy. FN event was identified using a diagnosis of neutropenia (ICD-10: D70.x) with associated fever (ICD-10: R50.2-R50.9) or infection (ICD-10: A40.x, A41.x, B95.0-B95.8, B96.0-B96.8, T80.21-T80.29) during the myelotoxic chemotherapy course. FN rates were evaluated overall and by cancer type, disease status, prior chemotherapy use, select comorbidities, age, curative or palliative intent, and treatment plan FN risk. Results: A total of 1,123 patients receiving 1,663 myelotoxic chemotherapy plans were identified. Patients were predominately female (60%) with a mean age of 61 years (SD: 14.1). A total of 66 patients experienced 79 FN events. Of these events, 70 (88.6%) resulted in a hospitalization. The FN rate during the study period was 5.9% (95% CI: 2.3%-10.2%). Factors associated with the highest FN rates were: lymphoid malignancy (9.9%), non-metastatic disease (7.2%), no prior chemotherapy (6.5%), ≥ 3 comorbidities. Conclusions: Our findings indicate it is feasible to estimate FN rates using a search algorithm with a known FN definition in the EMR of a large integrated delivery network. While additional analyses are planned to account for concomitant patient characteristics to fully understand the occurrence of FN, the current project nevertheless demonstrates the ability of estimating FN rates to both measure care quality and allow pursuing quality improvement (QI) initiatives for appropriate FN prophylaxis. The results also have the potential to serve as a benchmark for similar QI projects in other large healthcare systems.

Workplace wellness programs are increasingly popular. Employers expect them to improve employee health and well-being, lower medical costs, increase productivity, and reduce absenteeism. To test whether such expectations are warranted, we evaluated the cost impact of the lifestyle and disease management components of PepsiCo's wellness program, Healthy Living. We found that seven years of continuous participation in one or both components was associated with an average reduction of $30 in health care cost per member per month. When we looked at each component individually, we found that the disease management component was associated with lower costs and that the lifestyle management component was not. We estimate disease management to reduce health care costs by $136 per member per month, driven by a 29 percent reduction in hospital admissions. Workplace wellness programs may reduce health risks, delay or avoid the onset of chronic diseases, and lower health care costs for employees with manifest chronic disease. But employers and policy makers should not take for granted that the lifestyle management component of such programs can reduce health care costs or even lead to net savings.

This article leverages existing data on wellness programs to explore patterns of wellness program availability, employers' use of incentives, and program participation and utilization among employees. Researchers used two sets of data for this project: The first included data from the 2012 RAND Employer Survey, which used a nationally representative sample of U.S. employers that had detailed information on wellness program offerings, program uptake, incentive use, and employer characteristics. These data were used to answer questions on program availability, configuration, uptake, and incentive use. The second dataset included health care claims and wellness program information for a large employer. These data were analyzed to predict program participation and changes in utilization and health. The findings underscore the increasing prevalence of worksite wellness programs. About four-fifths of all U.S. employers with more than 1,000 employees are estimated to offer such programs. For those larger employers, program offerings cover a range of screening activities, interventions to encourage healthy lifestyles, and support for employees with manifest chronic conditions. Smaller employers, especially those with fewer than 100 employees, appear more reserved in their implementation of wellness programs. The use of financial incentives appears to increase employee participation in wellness programs, but only modestly. Employee participation in lifestyle management aspects of workplace wellness programs does not reduce healthcare utilization or cost regardless of whether we focus on higher-risk employees or those who are more engaged in the program.

Insufficient evidence regarding the effectiveness of medical treatments has been identified as a key source of inefficiency in the U.S. healthcare system. Variation in the use of diagnostic tests and treatments for patients with similar symptoms or conditions has been attributed to clinical uncertainty, since the published scientific evidence base does not provide adequate information to determine which treatments are most effective for patients with specific clinical needs. The federal government has made a dramatic investment in comparative effectiveness research (CER), with the expectation that CER will influence clinical practice and improve the efficiency of healthcare delivery. To do this, CER must provide information that supports fundamental changes in healthcare delivery and informs the choice of diagnostic and treatment strategies. This article summarizes findings from a qualitative analysis of the factors that impede the translation of CER into clinical practice and those that facilitate it. A case-study methodology is used to explore the extent to which these factors led to changes in clinical practice following five recent key CER studies. The enabling factors and barriers to translation for each study are discussed, the root causes for the failure of translation common to the studies are synthesized, and policy options that may optimize the impact of future CER-particularly CER funded through the American Recovery and Reinvestment Act of 2009-are proposed.

Trauma is a serious injury or shock to the body from violence or crash and is an important and growing global health risk. Using 2000 to 2004 data from a comprehensive trauma registry, we estimated the prevalence of serious blunt and penetrating trauma-related hemorrhage among patients admitted to U.S. trauma centers along with excess in-hospital mortality, length of hospital stay, and inpatient costs. There were 65,750 patients with blunt trauma and 12,992 patients with penetrating trauma included in our analyses. Of patients sustaining blunt trauma, 7.6 per cent had serious hemorrhage; 18.8 per cent of patients sustaining penetrating trauma had serious hemorrhage. In-hospital mortality rates were significantly ( P < 0.05) higher for patients with serious hemorrhage than for patients without (24.9 per cent versus 8.4 per cent for blunt; 23.4 per cent versus 4.2 per cent for penetrating). Patients with serious hemorrhage had adjusted mean excess lengths of stay of 0.4 days for blunt trauma and 2.7 days for penetrating trauma ( P < 0.05); adjusted excess costs were $296 per day for patients sustaining blunt trauma and $637 per day for patients sustaining penetrating trauma ( P < 0.05). In both blunt and penetrating trauma cases, serious hemorrhage is significantly associated with excess mortality, longer hospital stays, and higher costs.

Previous research suggests that erythropoiesis stimulating agent (ESA) administration in dialysis is a time-consuming task and switching to less frequently dosed ESAs may offer operational efficiencies. Our objective was to describe and measure the time spent on tasks in the ESA administration process in US dialysis centers, and to estimate potential efficiency gains of using weekly (QW) administration vs three-times-per-week (TIW) administration.We conducted a time and motion study of staff time required to prepare, administer and document ESA doses. Dialysis centers using intravenous administration of TIW epoetin alfa (EPO) or QW darbepoetin alfa (DPO) were selected in pairs (one EPO, one DPO) from the same organization to help control for differences in ESA protocols and staffing patterns across organizations. ESA-related tasks were timed by trained observers. Time savings of TIW vs QW administration were estimated. Staff were interviewed about alternate activities that could be accomplished if time were saved in the ESA process.A total of 200 administrations were observed (81 DPO, 119 EPO). A mean of 2.26 (95% CI: 2.1-2.5) minutes per dose were required for ESA administration. ESA process time per administration did not vary significantly between EPO and DPO (p = 0.83). Estimated potential monthly staff time savings for an average facility of 70 patients totaled 23 hours, due to fewer ESA administrations using QW DPO. Patient education and fulfillment of care plans were identified as opportunities for improved care processes that could be implemented if staff time was freed up from the ESA process.Results should not be generalized to other countries, ESAs and/or dosing frequencies.Switching from TIW EPO to QW DPO can result in time savings due to fewer administrations and provide opportunities to redirect nurse time towards activities aimed at improving patient care.

The costs of chronic obstructive pulmonary disease (COPD) pose a major economic burden to the United States. Studies evaluating COPD costs have generated widely variable estimates; we summarized and critically compared recent estimates of the annual national and per-patient costs of COPD in the U.S. Thirteen articles reporting comprehensive estimates of the direct costs of COPD (costs related to the provision of medical goods and services) were identified from searches of relevant primary literature published since 1995. Few papers reported indirect costs of COPD (lost work and productivity). The National Heart, Lung, and Blood Institute (NHLBI) provides the single current estimate of the total (direct plus indirect) annual cost of COPD to the U.S., $38.8 billion in 2005 dollars. More than half of this cost ($21.8 billion) was direct, aligning with the $20–26 billion range reported by two other recent analyses of large national datasets. For per-patient direct costs (in $US 2005), studies using recent dat...

The recent passage of the Affordable Care Act has heightened the importance of workplace wellness programs. This paper used administrative data from 2002 to 2007 for PepsiCo’s self-insured plan members to evaluate the effect of its wellness program on medical costs and utilization. We used propensity score matching to identify a comparison group who were eligible for the program but did not participate. No significant changes were observed in inpatient admissions, emergency room visits, or per-member per-month (PMPM) costs. The discrepancy between our findings and those of prior studies may be due to the difference in intervention intensity or program implementation.

Examines the return on investment (ROI) that companies realize from workplace wellness programs, focusing on the ROI provided by disease management programs versus lifestyle management programs.

This fact sheet describes the results of research into the factors influencing physician professional satisfaction and their implications for health care.

Workplace wellness programs have become increasingly common in the United States, but what do these programs look like? A 2012 national survey gives us the skinny on typical components, incentives for participation, and levels of employee engagement.

Objectives To assess, from a Swedish societal perspective, the cost effectiveness of interferon β-1b (IFNB-1b) after an initial clinical event suggestive of multiple sclerosis (MS) (ie, early treatment) compared with treatment after onset of clinically definite MS (CDMS) (ie, delayed treatment). Methods A Markov model was developed, using patient level data from the BENEFIT trial and published literature, to estimate health outcomes and costs associated with IFNB-1b for hypothetical cohorts of patients after an initial clinical event suggestive of MS. Health states were defined by Kurtzke Expanded Disability Status Scale (EDSS) scores. Model outcomes included quality-adjusted life years (QALYs), total costs (including both direct and indirect costs), and incremental cost-effectiveness ratios. Sensitivity analyses were performed on key model parameters to assess the robustness of model results. Results In the base case scenario, early IFNB-1b treatment was economically dominant (ie, less costly and more effective) versus delayed IFNB-1b treatment when QALYs were used as the effectiveness metric. Sensitivity analyses showed that the cost-effectiveness results were sensitive to model time horizon. Compared with the delayed treatment strategy, early treatment of MS was also associated with delayed EDSS progressions, prolonged time to CDMS diagnosis, and a reduction in frequency of relapse. Conclusion Early treatment with IFNB-1b for a first clinical event suggestive of MS was found to improve patient outcomes while controlling costs.

Trauma is a serious injury or shock to the body from violence or crash and is an important and growing global health risk. Using 2000 to 2004 data from a comprehensive trauma registry, we estimated the prevalence of serious blunt and penetrating trauma-related hemorrhage among patients admitted to U.S. trauma centers along with excess in-hospital mortality, length of hospital stay, and inpatient costs. There were 65,750 patients with blunt trauma and 12,992 patients with penetrating trauma included in our analyses. Of patients sustaining blunt trauma, 7.6 per cent had serious hemorrhage; 18.8 per cent of patients sustaining penetrating trauma had serious hemorrhage. In-hospital mortality rates were significantly (P0.05) higher for patients with serious hemorrhage than for patients without (24.9 per cent versus 8.4 per cent for blunt; 23.4 per cent versus 4.2 per cent for penetrating). Patients with serious hemorrhage had adjusted mean excess lengths of stay of 0.4 days for blunt trauma and 2.7 days for penetrating trauma (P0.05); adjusted excess costs were $296 per day for patients sustaining blunt trauma and $637 per day for patients sustaining penetrating trauma (P0.05). In both blunt and penetrating trauma cases, serious hemorrhage is significantly associated with excess mortality, longer hospital stays, and higher costs.