Short- and Long-Term Stroke Risk after Urgent Management of Transient Ischaemic Attack: The Bologna TIA Clinical Pathway.

BACKGROUND: Rapid management can reduce the short stroke risk after transient ischaemic attack (TIA), but the long-term effect is still little known. We evaluated 3-year vascular outcomes in patients with TIA after urgent care. METHODS: We prospectively enrolled all consecutive patients with TIA diagnosed by a vascular neurologist and referred to our emergency department (ED). Expedited assessment and best secondary prevention was within 24 h. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death at 12, 24 and 36 months. RESULTS: Between August 2010 and July 2013, we evaluated 686 patients with suspected TIA; 433 (63%) patients had confirmed TIA. Stroke at 90 days was 2.07% (95% confidence interval (CI), 1.1-3.9) compared with the ABCD2-predicted risk of 9.1%. The long-term stroke risk was 2.6% (95% CI, 1.1-4.2), 3.7% (95% CI, 1.6-5.9) and 4.4% (95% CI, 1.9-6.8) at 12, 24 and 36 months, respectively. The composite outcome of stroke, myocardial infarction, and vascular death was 3.5% (95% CI, 1.7-5.1), 4.9% (95% CI, 2.5-7.4), and 5.6% (95% CI, 2.8-8.3) at 12, 24, and 36 months, respectively. CONCLUSIONS: TIA expedited management driven by vascular neurologists was associated with a marked reduction in the expected early stroke risk and low long-term risk of stroke and other vascular events.

A Research Agenda to Better Understand the Human Dimensions of Energy Transitions.

The Social Sciences and Humanities (SSH) have a key role to play in understanding which factors and policies would motivate, encourage and enable different actors to adopt a wide range of sustainable energy behaviours and support the required system changes and policies. The SSH can provide critical insights into how consumers could be empowered to consistently engage in sustainable energy behaviour, support and adopt new technologies, and support policies and changes in energy systems. Furthermore, they can increase our understanding of how organisations such as private and public institutions, and groups and associations of people can play a key role in the sustainable energy transition. We identify key questions to be addressed that have been identified by the Platform for Energy Research in the Socio-economic Nexus (PERSON, see person.eu), including SSH scholars who have been studying energy issues for many years. We identify three main research themes. The first research theme involves understanding which factors encourage different actors to engage in sustainable energy behaviour. The second research theme focuses on understanding which interventions can be effective in encouraging sustainable energy behaviour of different actors, and which factors enhance their effects. The third research theme concerns understanding which factors affect public and policy support for energy policy and changes in energy systems, and how important public concerns can best be addressed as to reduce or prevent resistance.

Prospective observational cohort study of early recurrent TIA: Features, frequency, and outcome.

OBJECTIVES: To evaluate the frequency, clinical and etiologic features, and short- and long-term outcomes of early recurrent TIA. METHODS: This prospective observational cohort study enrolled all consecutive patients with TIA referred to our emergency department and diagnosed by a vascular neurologist. Expedited assessment and best secondary prevention were performed within 24 hours. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome, and vascular death at 3, 12, and, for a subset of patients, 60 months; secondary outcomes were TIA relapse, cerebral hemorrhage, new-onset atrial fibrillation, and death resulting from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated. RESULTS: A total of 1,035 patients (822 with a single TIA, 213 with recurrent TIA = 21%) were enrolled from August 2010 to December 2017. Capsular warning syndrome and large artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-up, and most stroke episodes occurred within 48 hours of index TIA. TIAs with lesion, dysarthria, and leukoaraiosis were the 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score >6 predicted a higher risk of stroke recurrence over the entire follow-up. CONCLUSIONS: Our study evaluated long-term outcome after early recurrent TIA. Our observations support the importance of promptly detecting and treating patients with early recurrent TIAs to reduce the high early and long-term risk of poor clinical outcomes.

The impact of ambient air pollution on hospital admissions.

Ambient air pollution is the environmental factor with the most significant impact on human health. Several epidemiological studies provide evidence for an association between ambient air pollution and human health. However, the recent economic literature has challenged the identification strategy used in these studies. This paper contributes to the ongoing discussion by investigating the association between ambient air pollution and morbidity using hospital admission data from Switzerland. Our identification strategy rests on the construction of geographically explicit pollution measures derived from a dispersion model that replicates atmospheric conditions and accounts for several emission sources. The reduced form estimates account for location and time fixed effects and show that ambient air pollution has a substantial impact on hospital admissions. In particular, we show that [Formula: see text] and [Formula: see text] are positively associated with admission rates for coronary artery and cerebrovascular diseases while we find no similar correlation for PM10 and [Formula: see text]. Our robustness checks support these findings and suggest that dispersion models can help in reducing the measurement error inherent to pollution exposure measures based on station-level pollution data. Therefore, our results may contribute to a more accurate evaluation of future environmental policies aiming at a reduction of ambient air pollution exposure.

Proximal and isolated distal deep vein thrombosis and Wells score accuracy in hospitalized patients.

Deep vein thrombosis (DVT) is an important cause of morbidity and mortality in hospitalized patients. The Wells score for DVT pretest probability (PTP) was validated in outpatients, but its utility for inpatients is unclear. The aim of this study was to establish the prevalence of inpatient proximal and distal DVT and the Wells score performance in inpatients. A single-center cross-sectional study was conducted in a university hospital. During 183 days, all inpatients with suspected lower-extremity DVT were evaluated with the Wells score and whole-leg ultrasound. Among 634 inpatients (age 77.5 ± 13.8 years, males 39.3%), 507 (80.0%) were from medical wards and 127 (20.0%) from surgical wards. During the study period, there were 11,662 hospital admissions in the surgical/medical services. Whole-leg ultrasound detected 128 DVTs (20.2%); 51 (39.8%) were proximal and 77 (60.1%) were isolated distal DVTs. Estimated DVT prevalence in hospital setting was 1.09% (95% CI 0.93-1.31), and isolated distal DVT prevalence was 0.66% (95% CI 0.53-0.82). DVT frequency in low-, moderate-, and high-PTP groups was 9.8%, 24.3%, and 41.5%, respectively (p = 0.001). The area under the receiver operating characteristic curve for the Wells score was 0.67 ± 0.03 for all DVTs and 0.75 ± 0.04 for only proximal DVTs. A high PTP had a sensitivity of 24% (95% CI 14-37%) and a specificity of 93% (95% CI 91-95%) for proximal DVT diagnosis. In hospitalized patients, isolated distal DVT has a higher incidence than expected, and the Wells score accuracy for proximal DVT is similar to that found in outpatients.

Socioeconomic determinants of regional differences in outpatient antibiotic consumption: evidence from Switzerland.

This paper investigates the determinants of regional variations in outpatient antibiotic consumption using Swiss data. The analysis contributes to the debate on appropriate antibiotic use by improving the understanding of its determinants, and may help to define more effective health care policies to reduce the resistance phenomenon. Findings suggest that Switzerland exhibits relatively low levels of consumption among European countries. There are significant differences between cantons both in the per capita antibiotic sales and defined daily doses per 1000 inhabitants (DID). Econometric estimations suggest that DID are significantly related to per capita income, antibiotic price, the density of medical practices, demographic, cultural and educational factors. The incidence of bacterial infections is also relevant. Appropriate policies affecting antibiotic consumption in the community can be designed by looking at crucial determinants in the model and their related impact.

Implications of global budget payment system on nursing home costs.

Pressure on health care systems due to the increasing expenditures of the elderly population is pushing policy makers to adopt new regulation and payment schemes for nursing home services. We consider the behavior of nonprofit nursing homes under different payment schemes and empirically investigate the implications of prospective payments on nursing home costs under tightly regulated quality aspects. To evaluate the impact of the policy change introduced in 2006 in Southern Switzerland - from retrospective to prospective payment - we use a panel of 41 homes observed over a 10-years period (2001-2010). We employ a fixed effects model with a time trend that is allowed to change after the policy reform. There is evidence that the new payment system slightly reduces costs without impacting quality.

Risk factors for recurrent events in subjects with superficial vein thrombosis in the randomized clinical trial SteFlux (Superficial Thromboembolism Fluxum).

BACKGROUND/AIMS: To evaluate risk factors for recurrent events in patients enrolled in the SteFlux (Superficial Thromboembolism Fluxum) clinical trial which compared different doses and duration of low molecular weight heparin (parnaparin) for superficial vein thrombosis (SVT). MATERIALS AND METHODS: Outpatients with acute SVT of at least 4 cm in length of the internal or external saphenous veins or their collaterals were randomized in a double blind fashion to receive either parnaparin 8500 UI aXa od for ten days followed by placebo for 20 days or 8500 UI aXa od for ten days followed by 6400 UI aXa od for 20 days or 4250 UI aXa od for 30 days. Outcomes were the composite of symptomatic and asymptomatic deep vein thrombosis, pulmonary embolism and SVT recurrence or extension in the first 30+/-3 days with a 60+/-3 day follow-up. RESULTS: 98 outcomes (14.7%) were recorded during 93 days among 664 patients (M/F: 246/418, mean age 65). After correction for treatment, outcomes during 33 days were associated with previous venous thromboembolism (VTE) and/or SVT and/or family history of VTE (odds ratio-OR: 2.5; 95% confidence interval - CI: 1.4-4.8; p=0.003). After stopping LMWH treatment, only the absence of varicose veins (OR: 2.5; 95% CI 1.3-5.0; p=0.004) and previous VTE and/or SVT and/or family history of VTE (OR: 1.9; 95% CI:1.0-3.7; p=0.048) were significantly associated with outcomes. CONCLUSIONS: SVT patients with these factors may deserve a higher intensity and/or longer anticoagulant treatment.

Socioeconomic determinants of outpatient antibiotic use in Europe.

OBJECTIVES: Outpatient antibiotic consumption widely varies across Europe. The investigation of the causes of such variation may help to identify interventions that would improve the efficient use of antibiotics. The aim of this study was to assess the impact of socioeconomic determinants and the role played by information about bacterial resistance. METHODS: Comparable data on systemically administered antibiotics and socioeconomic determinants in 17 European countries were available between 2000 and 2005. We estimated an ad hoc econometric model by means of a hybrid log-log functional form and random effects generalised least squares regressions. Lagged values and the instrumental variable method were applied to address endogeneity of bacterial resistance and infections. Bacterial resistance was measured by the rate of penicillin non-susceptible Streptococcus pneumoniae isolates (PNSP) and methicillin-resistant Staphylococcus aureus (MRSA). RESULTS: The population income, demographic structure, density of general practitioners and their remuneration method appeared to be significant determinants of antibiotic consumption. Although countries with higher levels of bacterial resistance exhibited significantly higher levels of per capita antibiotic use, ceteris paribus, the responsiveness of antibiotic use to changes in bacterial resistance was relatively low (0.09-0.18). CONCLUSIONS: The study confirms that socioeconomic factors should be taken into account while explaining differences in outpatient antibiotic use across countries. The impact of supply-side factors and incentives attached to payment schemes for physicians need to be considered in government interventions to reduce inequalities and improve effectiveness in antibiotic utilisation.

Small area variations and welfare loss in the use of outpatient antibiotics.

This article seeks to explain local variations in the use of antibiotics in the community and to assess the welfare loss due to heterogeneous attitudes towards the risk of bacterial resistance. Quarterly data on antibiotic sales from 240 small areas in Switzerland over the course of one year are used. An econometric ad-hoc model with spatial lags is proposed in which the demand for antibiotics varies according to the socioeconomic characteristics of the population, the incidence of infections, antibiotic price and local health care supply. Using residual variations we then evaluate the welfare loss due to varying antibiotic prescription styles. Significant differences are observed in the per capita antibiotic consumption across local areas. Individual income, the demographic structure of the population, physician density and the price of drugs are all relevant determinants. We estimate that unexplained variations may account for 12% of the total antibiotic spending in the community, thus leading to a Euro 6.8 ml loss per year. Understanding the determinants of variations in outpatient antibiotic consumption may help to design more effective policies to counter the threat of bacterial resistance. Our estimate of the welfare loss due to heterogeneous attitudes towards antibiotic treatment is comparable to the expected cost of implementing measures to improve the dissemination of information on bacterial resistance among patients and doctors.

Effects of ownership, subsidization and teaching activities on hospital costs in Switzerland.

This paper explores the cost structure of Swiss hospitals, focusing on differences due to teaching activities and those related to ownership and subsidization types. A stochastic total cost frontier with a Cobb-Douglas functional form has been estimated for a panel of 148 general hospitals over the six-year period from 1998 to 2003. Inpatient cases adjusted by DRG cost weights and ambulatory revenues are considered as two separate outputs. The adopted econometric specification allows for unobserved heterogeneity across hospitals. The results suggest that teaching activities are an important cost-driving factor and hospitals that have a broader range of specialization are relatively more costly. The excess costs of university hospitals can be explained by more extensive teaching activities as well as the relative complexity of the offered medical treatments from a teaching point of view. However, even after controlling for such differences university hospitals have shown a relatively low cost-efficiency especially in the first two or three years of the sample period. The analysis does not provide any evidence of significant efficiency differences across ownership/subsidy categories.

Federalism and regional health care expenditures: an empirical analysis for the Swiss cantons.

Switzerland (7.2 million inhabitants) is a federal state composed of 26 cantons. The autonomy of cantons and a particular health insurance system create strong heterogeneity in terms of regulation and organisation of health care services. In this study we use a single-equation approach to model the per capita cantonal expenditures on health care services and postulate that per capita health expenditures depend on some economic, demographic and structural factors. The empirical analysis demonstrates that a larger share of old people tends to increase health costs and that physicians paid on a fee-for-service basis swell expenditures, thus highlighting a possible phenomenon of supply-induced demand.

Regulation, ownership and efficiency in the Swiss nursing home industry.

Switzerland is a federal State where policy decisions regarding long-term care regulation are by rights incumbent upon regional and local governments. This situation is in part responsible for the large number of small nursing homes operating in Switzerland. Moreover, long-term care for the elderly is supplied by public, private for-profit and non-profit nursing homes, respectively. The paper presents an econometric estimation of a stochastic cost frontier using cross-section data for a sample of 886 Swiss nursing homes operating in 1998. The results of this analysis are used to examine the relationship between cost efficiency, the alternative institutional forms and the different regulatory settings.