Are cost advantages from a modern Indian hospital transferable to the United States?

BACKGROUND: Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals' cost advantages to US peers remains unclear. METHODS: Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH's cost savings. RESULTS: After removing non-transferable sources of efficiency, NH's residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH's high annual CABG volume facilitates such supervised work "downshifting." The study is subject to limitations inherent in case studies, does not account for the younger age of NH's patients, or capture savings attributable to NH's negligible frequency of re-admission or post-acute care facility placement. CONCLUSIONS: Most transferable bases for a modern Indian hospital's cost advantage would require more flexible American states' hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

Three-year experience of a dedicated prostate mpMRI pre-biopsy programme and effect on timed cancer diagnostic pathways.

AIM: To evaluate the effect of pre-biopsy magnetic resonance imaging (MRI) on cancer diagnostic times, and to report MRI-directed pathology outcomes. MATERIALS AND METHODS: In total, 1483 patients were referred with prostate cancer suspicion during a 30-month period. Upfront MRI was performed in 745 patients: 332 MRIs in the 15 months prior to dedicated scanning slots (group 1), and 413 in the 15 months post-introduction (group 2). A further 88 patients had initial MRI following clinical assessment. Biopsy via the transrectal (TR) or transperineal (TP) approach was performed, with MRI/ultrasound fusion for MRI targets. Clinically significant cancer (csPCa) was defined as Gleason ≥3+4. Negative MRIs were defined as Likert 1-2. Per-case clinical decisions were taken to biopsy or not. RESULTS: 44.4% of patients avoided biopsy. 484/833 (58.1%) MRIs were negative; 37.4% of these patients had biopsy with a negative predictive value (NPV) of 92.8% for Gleason ≥3+4 and 98.3% for ≥4+3. Overall prostate cancer prevalence was 34.3% (24.6% csPCa). In 323 MRI-positive cases, any cancer was present in 78.9% (csPCa 60.4%). Of the 1483 patients, 1232 (83.1%) completed all diagnostic tests within 28 days. Upfront MRI patients met this standard in 621/833 (74.5%), improving from 66.9% to 81.1% with reserved slots (group 2) with a reduced diagnostic time from median 25.5 to 20.9 days. Biopsy scheduling delayed the pathway in 69.7%, with MRI responsible in 22.3%, reducing to 10.3% in group 2. TP biopsies met the 28-day standard in significantly less cases (29.7%), compared to TR (67.4%, p<0.0001). CONCLUSION: Reserved MRI slots reduces time-to-diagnosis, and upfront MRI safely avoids biopsy in a significant proportion of men, whilst maintaining expected csPCa detection rates.

Results of an exercise to estimate the costs of interpersonal violence in Jamaica.

UNLABELLED: This report describes the application of a draft version of the World Health Organization (WHO)/ United States Centers for Disease Control and Prevention (CDC) Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence to measure costs of injuries from interpersonal violence. METHODS: Fatal incidence data was obtained from the Jamaica Constabulary Force. The incidence of nonfatal violence-related injuries that required hospitalization was estimated using data obtained from patients treated at and/or admitted to three Type A government hospitals in 2006. RESULTS: During 2006, direct medical cost (J$2.1 billion) of injuries due to interpersonal violence accounted for about 12% of Jamaica's total health budget while productivity losses due to violence-related injuries accounted for approximately J$27.5 billion or 160% of Jamaica's total health expenditure and 4% of Jamaica's Gross Domestic Product. CONCLUSIONS: The availability of accurate and reliable data of the highest quality from health-related information systems is critical for providing useful data on the burden of violence and injury to decision-makers. As Ministries of Health take a leading role in violence and injury prevention, data collection and information systems must have a central role. This study describes the results of one approach to examining the economic burden of interpersonal violence in developing countries where the burden of violence is heaviest. The WHO-CDC manual also tested in Thailand and Brazil is a first step towards generating a reference point for resource allocation, priority setting and prevention advocacy.

Older men's concerns about their urological health: a qualitative study.

While there has been widespread recent interest in men's health issues, and prostate cancer in particular, there have been few studies to determine which issues are important from the viewpoint of men themselves. This study was undertaken to identify genitourinary issues of concern to older men. A series of 19 focus groups involved 137 men and 14 women from a broad demographic background. Men expressed consistent concern about urinary symptoms, prostate cancer and sexual function. They revealed misunderstanding and a desire for more information about all issues. Urinary symptoms had a high impact on quality of life that could be made worse by environmental constraints such as working conditions and availability of toilets. Prostate cancer was a concern in all groups, even those at low risk, and men believed that screening for prostate cancer should be offered. Men believed sexuality was not recognised as an issue of concern to older people. Potential barriers to health action included stoicism, not talking about health issues and poor relationships with doctors. The study suggests a substantial need for community and professional education and for health promotion focused on preventable morbidity.

Prostate cancer testing in SA men: influence of sociodemographic factors, health beliefs and LUTS.

This study investigates the prevalence and determinants of prostate cancer screening in the South Australian community. An interview-based survey of a probability sample of the SA population (N = 3,016) in 1995 addressed previous PSA testing, beliefs about vulnerability to prostate cancer and efficacy of screening, presence of uncomplicated lower urinary tract symptoms (LUTS) and sociodemographic variables. Of 736 men, 40 years and over with no history of prostate cancer, 24.7% (182/736) reported ever having had a test and 53.9% (397) reported an intention to test; 74% (547) agreed that prostate cancer could be cured if detected early, while only 14.9% (109) believed they were unlikely to suffer from prostate cancer. In a logistic regression model, visit to a doctor for (but not presence of) LUTS was a strong, independent predictor of participation in PSA testing (OR 9.0, 95% CI 5.0, 16.0). Beliefs, occupation and education were not. In a similar model examining intention to test, belief in vulnerability to prostate cancer was the strongest predictor (OR 3.32, 95% CI 1.9, 5.9), followed by doctor visit for urinary symptoms. These data are consistent with widespread PSA testing and with seeking treatment for LUTS being a major determinant of previous testing. NHMRC Clinical Guidelines for LUTS recommend against PSA testing for investigation of uncomplicated LUTS. Implementation of those guidelines may therefore have a significant effect on PSA testing rates. Belief in personal vulnerability to prostate cancer remains a significant component of reported future testing, suggesting a focus for community education.

Attitudes to evidence-based practice in urology: results of a survey.

BACKGROUND: The advantages of promoting evidence-based care through implementation of clinical guidelines are well established. Clinical practice guidelines have been developed for lower urinary tract symptoms (LUTS) and prostate cancer screening. Aspects of the delivery of care by urologists or specialist registrars relevant to the guidelines were assessed. METHODS: A questionnaire was distributed at the 1999 meeting of the Urological Society of Australasia, which was attended by 187 Australasian and 33 foreign delegates. Questions addressed access to resources for evidence-based medicine; perceived need; preferred sources of information; and then presented four clinical scenarios. These were: (i) treatment recommendations in early stage prostate cancer; (ii) the same scenario if the respondent was the patient; (iii) treatment recommendations after radical prostatectomy when there was a positive resection margin; and (iv) clinical investigations for mild to moderate LUTS. RESULTS: Of 220 possible responses, 132 were received, a response rate of 60%. Urologists overwhelmingly (100%) endorsed the need for access to evidence-based reviews, although 28% claimed such access was non-existent to poor. Clinical guidelines were the preferred source of evidence-based information. For early stage prostate cancer in a 55-year-old man, radical prostatectomy was recommended by 93.2% of respondents, but this dropped to 83% when the respondent was the patient (P < 0.05), and a wider range of treatments was recommended. Pelvic radiotherapy and hormone therapy were equally recommended for biochemical progression following radical prostatectomy where there was a positive surgical margin. Investigations for LUTS included serum prostate-specific antigen (PSA) testing (78.0%) and voided flow studies (77.3%). CONCLUSIONS: Urologists express a need for evidence-based practice resources, in particular clinical guidelines. Nevertheless their clinical approach is not necessarily consistent with existing guidelines, particularly for LUTS. An alteration in the recommendation when the respondent is the patient of interest and endorses the recommendation that patients with prostate cancer should be involved in treatment decisions.

Vitamin A.

PIP: 20-40 million children in the world have mild vitamin A deficiency and another 3 million have severe vitamin A deficiency leading to high rates of xerophthalmia and blindness. Vitamin A influences growth, survival, and resistance to infection. Vitamin A deficiency reduces the T-cells' ability to fight infection and decreases mucous production resulting in more bacteria being able to attach themselves to respiratory mucosa. Thus it increases the body's susceptibility to respiratory infection. For example, health workers in rural Indonesia who followed children for 18 months and learned that those with mild vitamin A deficiency are twice the risk of respiratory infection than those who do not have such a deficiency. This risk is higher regardless of the children's overall nutritional status. A study in urban India shows the same results. A study in Ethiopia finds children with xerophthalmia not only at increased risk of respiratory infection but also of diarrhea. Other studies demonstrate that respiratory disease, diarrhea, and measles precipitate vitamin A deficiency. For example, corneal ulceration follows an episode of measles in 79% of all corneal ulceration cases in Tanzania. In Indonesia, children with measles are 11 times more likely to have xerophthalmia. Children with mild vitamin A deficiency in Indonesia face death 4 time more often than those with no such deficiency. Vitamin A supplementation decreases mortality 72% in 60-71 month old children and 15% in 12-23 month old children, yet increases it 23% in 36-47 month old children. In Ethiopia, an infection is more predictive of severe, symptomatic vitamin A deficiency than is preexisting malnutrition. Still vitamin A deficiency increases the likelihood of respiratory infection and diarrhea. Thus vitamin A deficient children enter a downward spiral. The longterm solution to vitamin A deficiency is community development and increased consumption of dark green edible plants and red and orange fruits.^ieng

The fatty acid profile of vegetative Azotobacter vinelandii ATCC 12837: growth phase-dependence.

Fatty acids of Azotobacter vinelandii ATCC 12837 were determined at various times during aerobic vegetative growth at 30 degrees C to provide baseline data for studying the effects of chemical agents on the organism's survival and fatty acid biosynthesis. Palmitate (16:0) was the highest at 36.7+/-4.3 mol% (mean+/-SD) after the first 5 h in fresh culture, decreasing slightly to 33.4+/-2.6 mol% at 49 h. The other fatty acids were therefore each normalized as a ratio of 16:0. At 5 h, as a ratio of 16:0, myristate (14:0) was 0.14+/-0.06, palmitoleate (16:1cDelta9-10) 0.13+/-0.06, oleate (18:1cDelta9-10) 0.21+/-0.12, cis-vaccenate (18:1cDelta11-12) 0.30+/-0.17 and stearate (18:0) 0.68+/-0.02. As the growth phase advanced to 49 h, 14:0 and 16:1cDelta9-10 increased, 18:1cDelta9-10 decreased and cis-vaccenate reciprocally increased, whereas 18:0 decreased. These suggest that the saturated fatty acid biosynthesis pathway yielded 16:0 and 18:0 in the 5-h lag period. By desaturation, 18:0 formed the unsaturated fatty acid (UFA) 18:1cDelta9-10. As the culture aged, the anaerobic UFA biosynthesis pathway formed 16:1cDelta9-10, which was elongated to 18:1cDelta11-12. These fatty acid alterations represent a homeoviscous adaptation, modulating the microbe's membrane lipid viscosity for optimal cellular function.

The milk-mucus belief: sensory analysis comparing cow's milk and a soy placebo.

A questionnaire designed to measure the "milk mucus effect" was based on sensations and symptoms after drinking milk reported in interviews with 169 individuals, 70 of whom held the belief that milk produces mucus. This was used to measure responses in a randomized, double-blind trial of a flavoured UHT cow's milk drink, compared with a similarly flavoured and constituted UHT soy milk drink. The soy placebo was indistinguishable from cow's milk in a pretest of 185 individuals. Of 14 milk-mucus effect indicator variables, three showed significant increases after consumption of 300 ml of the test drink. These were "coating/lining over the mouth, throat or tongue" (39% increase), "need to swallow a lot" (31% increase) and "saliva thicker, harder to swallow than before" (42% increase). However, these increases occurred in both milk and placebo groups. It is concluded that the effect measured is not specific to cow's milk, but can be duplicated by a non-cow's milk drink with similar sensory characteristics.

The milk mucus belief: sensations associated with the belief and characteristics of believers.

The belief that milk produces mucus is widespread in the community and is associated with a significant reduction in milk consumption. Sensations associated with milk drinking were reported by otherwise healthy believers and non-believers in the milk-mucus effect (N = 169) in an unstructured interview, with further responses prompted about the duration, type and amount of milk causing the effect. The site predominantly affected was the throat, with sensations related to difficulty in swallowing and perceived thickness of mucus and salivary secretions, rather than excessive mucus production. The effect required only a small amount of milk and was reported to be of short duration. The chronic respiratory symptom history and dairy product intake of 130 of these subjects were also assessed. Milk-mucus believers were different from non-believers, reporting more respiratory symptoms and consuming less milk and dairy products. Symptoms consistent with the known effects of food allergy or intolerance were not reported.

The potential for teratogenicity of vitamin A and its congeners.

OBJECTIVE: To review the evidence for teratogenic potential associated with the use of vitamin A and synthetic retinoids in Australia. DATA SOURCES: Relevant indexed journal articles and standard drug information reference texts were identified by Medicine and library search. Information was also obtained from the Australian National Perinatal Statistics Unit. DATA EXTRACTION: We summarised human and animal data relating to the teratogenicity of vitamin A derivatives and synthetic retinoids, including case reports documenting systemic effects from topically administered drugs, pertinent information relating to the clinical pharmacokinetics and adverse effects of these compounds, and the approved and potential indications for the use of these agents. DATA SYNTHESIS: Extensive experimental evidence points to the teratogenicity of natural and synthetic retinoids in animals. Data confirming an effect in humans are not as good. Nevertheless case series, case reports and some epidemiological data regarding isotretinoin suggest that synthetic retinoids are similarly teratogenic in humans. Although there are extensive guidelines and legislation dealing with the use of these compounds in the United States and Australia, the potential for teratogenicity induced by vitamin A still exists. This is because retinoids and vitamin A continue to be prescribed for women of child-bearing potential and documented evidence from the United States reveals that not all prescribers comply with recommendations that minimise the risk of malformations. Non-prescription forms of vitamin A are available without a pregnancy hazard warning, and potentially teratogenic amounts are available from dietary sources. CONCLUSIONS: There exists a potential for teratogenicity in association with the use of both synthetic and natural retinoids in Australia. Monitoring systems currently in place in this country may not detect these malformations should they occur.

Troublesome lower urinary tract symptoms in the community: a prevalence study.

OBJECTIVE: To determine the prevalence of troublesome lower urinary tract symptoms (LUTS) in men and women in the community. DESIGN: Interview-based prevalence survey. SETTING: Metropolitan and rural communities in South Australia, September, 1995. SUBJECTS: Probability sample of 1204 men and 1686 women (aged over 18 years) weighted to reflect the age and sex distribution of the South Australian population. DATA COLLECTED: Presence of storage (irritative) and voiding (obstructive) symptoms, based on the International Prostate Symptom Score questionnaire; satisfaction with urinary condition (quality-of-life measure); and visits to a doctor for urinary symptoms in the preceding 12 months. RESULTS: The prevalence of one or more troublesome LUTS was 26% (318/1204) for men and 39% (662/1686) for women (all ages) and 48% (314/649) for men and women over 65. The most common troublesome symptoms in men and women were nocturia and frequency. Symptoms were significantly age-related in men, but less so in women, in whom symptom prevalence exceeded 30% for all age groups. Ten per cent of men (123/1204) and 15% of women (249/1686) had visited a doctor for a urinary problem in the previous 12 months. Nine per cent of men (104/1204) and 16% of women (274/1686) were substantially dissatisfied with their urinary condition. Symptom prevalence and dissatisfaction with urinary condition were significantly associated with visiting the doctor (P < 0.0001), but only 28% (88/318) of men and 27% (179/662) of women with troublesome LUTS saw a doctor, and 63% (65/104) of men and 59% (162/274) of women dissatisfied with their urinary condition did not seek medical help. CONCLUSIONS: Although the prevalence of troublesome LUTS in the community is high, the number of people whose quality of life is substantially affected is much lower. The impact of these symptoms upon quality of life is a major reason for patients to see a doctor, yet many who are "bothered" by the symptoms do not do so.

Preoperative urodynamic and symptom evaluation of patients undergoing transurethral prostatectomy: analysis of variables relevant for outcome.

OBJECTIVE: To assess the value of preoperative symptom score assessment and pressure-flow measurement in men undergoing transurethral prostatectomy (TURP). PATIENTS AND METHODS: In a prospective study, 95 men (mean age 74.3 years) scheduled for TURP because of their lower urinary tract symptoms, flow rates and urinary residual volumes were assessed using the self-administered International Prostate Symptom Score (IPSS) and urodynamic pressure-flow studies. At 3 months after TURP the patients were reassessed with a flow rate measurement and the IPSS. The baseline IPSS and urodynamic values were analysed with respect to the endpoints of the study, flow rate and IPSS after TURP, and the improvements thereof, respectively. RESULTS: There were significant improvements in mean IPSS (- 10.87 points) and peak flow rate (+ 7.06 mL/s) 3 months after TURP. Classifying the patients into subgroups with distinctly different initial values for IPSS, flow rate, residual urine volume and degree of obstruction (as expressed by Abrams-Griffiths number) showed that the flow rate and degree of obstruction influenced the improvement in flow rate but not in symptoms after TURP. Symptom improvement was only related to the initial level of symptoms. In a multivariate analysis, only age was an independent predictor of the outcome variables of flow rate and symptoms. CONCLUSIONS: Clinical decision-making remains a valid instrument for selecting patients for TURP. Both the IPSS and pressure-flow assessment are useful to exclude patients who are unlikely to benefit from TURP. Age is an important predictor of the improvement in symptoms and flow rates after TURP for the lower urinary tract symptom complex associated with benign prostatic enlargement.

Vitamin A status in children who are prone to respiratory tract infections.

The effect of Vitamin A supplementation on susceptibility to acute respiratory infections was investigated in a randomized controlled trial. One hundred and forty-seven preschool-age children with a history of frequent respiratory illness were randomized into Vitamin A supplemented (450 micrograms/day) and placebo groups. Respiratory symptoms were recorded on a daily basis over a period of 11 months. The children who received the supplement experienced 19% fewer episodes of respiratory symptomatology (P less than 0.05) than their placebo counterparts, despite the fact that their plasma retinol levels did not change. Children with a prior history of lower respiratory illness or of allergy benefited most from supplementation. The plausibility of a role for Vitamin A in the aetiology of respiratory proneness is reviewed.

Does evaluation with the International Prostate Symptom Score predict the outcome of transurethral resection of the prostate?

PURPOSE: We determined the reliability of the International Prostate Symptom Score (I-PSS) in predicting the outcome of transurethral prostatectomy and, therefore, how useful it can be in patient selection for surgery. MATERIALS AND METHODS: A prospective trial was done of 105 consecutive patients undergoing transurethral prostatectomy at our institution. Patients were assessed with the I-PSS before and 3 months after surgery. Flow rates and preoperative residual volumes also were measured. RESULTS: There was significant postoperative improvement in all parameters of the symptom score and a change in symptom profile. Symptoms remaining with the greatest scores at 3 months postoperatively were frequency, urgency and nocturia. A significant correlation was found between I-PSS and quality of life before and after transurethral prostatectomy, and between postoperative improvement in flow rates and change in I-PSS. Patients with a greater preoperative I-PSS gained the most symptomatic benefit. The positive predictive value of a significant postoperative improvement of at least 7 I-PSS points depended on the preoperative I-PSS criteria applied. With a preoperative I-PSS of more than 17 the positive predictive value was 87% with a corresponding negative predictive value of 71%. CONCLUSIONS: The preoperative I-PSS predicted a symptomatic improvement of more than 7 points with high sensitivity. The predictive value depends on the definition of significant improvement (magnitude of I-PSS change) and the level of I-PSS symptoms defined as sufficient to warrant transurethral prostatectomy.

Pelvic floor exercises as a treatment for post-micturition dribble.

OBJECTIVE: To determine the effectiveness of pelvic floor exercises and urethral milking as treatments for post-micturition dribble. PATIENTS AND METHODS: A method of measuring small amounts of urine loss during normal activity was developed; pads were worn for short periods (< 4 h) and then stored in two sealed plastic bags which were weighed within 72 h. Forty-nine men (age range 36-83 years) drawn from a hospital out-patient population, who had not undergone surgery on the bladder, urethra or prostate gland, entered the study. They were randomly assigned to one of three treatment groups; pelvic muscle exercise, urethral milking or counselling. Participants in each group followed the treatment specific to their group for 12 weeks. At 5, 9 and 13 weeks, urine loss was assessed using the method described. RESULTS: The groups were comparable for age, height, weight and pelvic muscle contraction strength and compliance of the men who completed the study was excellent. The outcome measure (improvement in pad weight gain) was strongly influenced by initial pad weight gain, or degree of urine loss at the start of the study and this was treated as a covariate in an analysis of variance model. After allowing for the effects of initial pad weight gain, the counselling group showed no improvement, the urethral milking group showed an adjusted mean improvement in urine loss of 2.9 g after 13 weeks, compared with 4.7 g in the exercise group. CONCLUSION: Both pelvic floor exercises and urethral milking are effective treatments for post-micturition dribble compared with counselling alone. Pelvic floor exercises were more effective in reducing urine loss than urethral milking in this study.

Stimulatory effects of peptides on growth of the free-living nematode Caenorhabditis briggsae.

Evidence is presented that peptide products of hydrolysis of casein, including some di- and tripeptides, but not the constituent amino acids, can stimulate growth of C. briggsae in defined basal medium supplemented with cytochrome C and B-sitosterol. Peptide activity may raise from amino acid imbalances in the medium which causes competitive inhibition of uptake of essential amino acids. Such activity precludes facilitation of heme transport as the sole function of growth factor in C. briggsae. This is the first report in a nutritional role of peptides in invertebrate metazoa.