Contrast-specific propensity scores for causal inference with multiple interventions.

Existing methods that use propensity scores for heterogeneous treatment effect estimation on non-experimental data do not readily extend to the case of more than two treatment options. In this work, we develop a new propensity score-based method for heterogeneous treatment effect estimation when there are three or more treatment options, and prove that it generates unbiased estimates. We demonstrate our method on a real patient registry of patients in Singapore with diabetic dyslipidemia. On this dataset, our method generates heterogeneous treatment recommendations for patients among three options: Statins, fibrates, and non-pharmacological treatment to control patients' lipid ratios (total cholesterol divided by high-density lipoprotein level). In our numerical study, our proposed method generated more stable estimates compared to a benchmark method based on a multi-dimensional propensity score.

Psychological safety in the perioperative environment: a cost-consequence analysis.

INTRODUCTION: Psychologically unsafe healthcare environments can lead to high levels of staff turnover, and unwanted financial burden. In this study, we investigate the hypothesis that lower levels of psychological safety are associated with higher levels of turnover, within an anaesthesiology department and we estimate the cost attributable to low psychological safety, driven by turnover costs. METHODS: Psychological safety was measured in one academic department. The psychological safety score was correlated with 'intention to leave' using linear regression and Pearson correlation and a cost-consequence analysis was performed. RESULTS: One hundred and thirty-eight physician anaesthesiologists (MDs) and 282 certified registered nurse anaesthetists (CRNAs) were surveyed. The response rate was 67.4% (93/138) for MDs and 60.6% (171/282) for CRNAs. There was an inverse relationship between psychological safety and turnover intent for both MDs (Pearson correlation -0.373, p value <0.0002) and CRNAs (Pearson correlation -0.486, p value <0.0002). The OR of intent to turn over in the presence of low psychological safety was 6.86 (95% CI 1.38 to 34.05) for MDs and 8.93 (95% CI 4.27 to 18.68) for CRNAs. The cost-consequence analysis demonstrated the cost of low psychological safety related to turnover per year was $337, 428 for MDs and $14, 024, 279 for CRNAs. Reducing low psychological safety in CRNAs from 31.6% to 20% reduces the potential cost of low psychological to $8 876 126.03. CONCLUSION: There is a cost relationship between low psychological safety and turnover. Low psychological safety in an academic anaesthesiology department may result in staff turnover, and potentially high financial costs.

Treating acutely ill patients at home: Data from Singapore.

INTRODUCTION: Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes. METHODS: We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge. RESULTS: A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again. CONCLUSION: Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.

Association of Use of Electronic Appointment Reminders With Waiting Times in the Veterans Affairs Health System.

Importance: Electronic appointment reminder systems are increasingly used across health systems. However, their association with patients' waiting times for their appointments, a measure of timely access to care, has yet to be assessed. Objective: To assess the associations between the introduction of an electronic appointment reminder system and the number of days patients had to wait from appointment booking to appointment completion in patients in the Veterans Affairs Health System. Design, Setting, and Participants: Cohort study of patients who completed appointments from January 1, 2018, to October 13, 2018, inclusive in all 130 Veterans Affairs (VA) health centers in the US. The study population comprised a census of all patients who received care at any VA health center during the period of the study for outpatient, procedural, rehabilitation, or radiology services. Data were analyzed from May 15, 2021, to December 15, 2021. Exposures: Phased introduction of an electronic appointment reminder system (VEText) in 6 waves spread across the study period. Main Outcomes and Measures: The unit of observation in this study was a completed appointment made by any such patients. Observations were excluded if the appointment was booked before but completed after the exposure, or if data were duplicated, missing, or incomplete. For each completed appointment, the number of days between which the appointment was booked and when it was completed. Results: The number of observations after exclusion comprised 39.5 million completed appointments from 5.1 million patients (91.1% male) with a mean (SD) age of 62.57 (16.24) years. The adoption of VEText was associated with an estimated reduction in patient waiting time by a mean of 6.51 days (95% CI, 5.51-7.52 days). Adoption of VEText was also associated with an increase of 8.54 (95% CI, 7.65-9.44) days of additional waiting per incomplete booking. Conclusions and Relevance: Results of this study suggest that appointment reminder systems may be associated with decreases in the mean number of days patients in the VA system have to wait for their appointments but can potentially lengthen waiting times for patients who miss their bookings. Further study is warranted to assess whether these findings may be generalizable to other populations.

Association of the FRAIL scale with rehabilitation outcomes in the community hospital setting.

Introduction: Frailty is associated with adverse health outcomes and can be measured using the FRAIL scale. In Singapore, its use has been studied in tertiary hospitals but not in community hospitals. A tool to predict rehabilitation outcomes would allow for better risk stratification and allocation of resources. We aimed to determine whether the FRAIL scale is associated with rehabilitation outcomes in patients admitted to the community hospital setting, where post-acute care and rehabilitation are primarily delivered. Methods: This was a retrospective cohort study. The FRAIL scale was utilised to screen 560 older adults who were admitted to a community hospital for rehabilitation. Data were analysed to determine the relationship between baseline characteristics and frailty status, with rehabilitation outcome measures of absolute functional gain, rehabilitation effectiveness, rehabilitation efficiency, length of stay and discharge destination. Results: The combined score of the FRAIL scale showed significant negative association with absolute functional gain (P < 0.001), rehabilitation effectiveness (P < 0.001) and rehabilitation efficiency (P < 0.001), whereas it was positively associated with increased length of stay (P < 0.05) and a need for continued support in increased care settings (P < 0.001). Individual components of the FRAIL scale, in particular, the 'fatigue', 'ambulation' and 'loss of weight' components, appeared to be highly associated with rehabilitation effectiveness and efficiency, especially among pre-frail patients. Conclusion: The utility of the FRAIL scale as an indicator of frailty status and its association with rehabilitative outcomes in the post-acute care setting were demonstrated. Moreover, the FRAIL scale may better predict the rehabilitative progress of pre-frail patients.

Asian Attitudes and Perceptions Toward Hospital-At-Home: A Cross-Sectional Study.

Introduction: Hospital-at-Home (HaH) programmes are well-established in Australia, Europe, and the United States. However, there is limited experience in Asia, where the hospital is traditionally seen as a safe and trusted space for healing. This cross-sectional study aimed to explore attitudes and perceptions among patients and caregivers in Singapore toward this care model. Methods: A quantitative study design was adopted to collect data among patients and their caregivers from medical wards within two acute hospitals in Singapore. Using a series of closed-ended and open-ended questions, the investigator-administered survey aimed to explore barriers and facilitators determining patients' and caregivers' responses. The study questionnaire was pretested and validated. Data were summarised using descriptive statistics, and logistic regression was performed to determine key factors influencing patients' decisions to enrol in such programmes. Results: Survey responses were collected from 120 participants (101 patients, 19 caregivers; response rate: 76%), of which 87 respondents (72.5%) expressed willingness to try HaH if offered. Many respondents valued non-quantifiable programme benefits, including perceived gains in quality of life. Among them, reasons cited for acceptance included preference for the comfort of their home environment, presence of family members, and confidence toward remote monitoring modalities. Among respondents who were unwilling to accept HaH, a common reason indicated was stronger confidence toward hospital care. Discussion: Most patients surveyed were open to having acute care delivered in their home environment, and concerns expressed may largely be addressed by operational considerations. The findings provide useful insights toward the planning of HaH programmes in Singapore.

Estimating the Attributable Cost of Physician Burnout in the United States.

Background: Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout. Objective: To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels. Design: Cost-consequence analysis using a mathematical model. Setting: United States. Participants: Simulated population of U.S. physicians. Measurements: Model inputs were estimated by using the results of contemporary published research findings and industry reports. Results: On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year. Limitations: Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated. Conclusion: Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.

Apnoeic and Hypopnoeic Load in Obstructive Sleep Apnoea: Correlation with Epworth Sleepiness Scale.

INTRODUCTION: Patients with obstructive sleep apnoea (OSA) often present with excessive daytime sleepiness (EDS) as measured by the Epworth Sleepiness Scale (ESS). However, the relationship between EDS and OSA severity as measured by the apnoea-hypopnoea index (AHI) remains inconsistent. We hypothesise that this may be due to the usage and equal weightage of apnoea and hypopnoea events used in determining AHI and that apnoea and hypopnoea load as measured by their total durations may be a better metric to use. We sought to investigate if apnoea or hypopnoea load can display better correlation with ESS. MATERIALS AND METHODS: Retrospective analysis of 821 patients with AHI ≥5, who underwent in-laboratory polysomnogram for suspected OSA from January 2015-December 2015, was performed. Objective factors on polysomnogram were correlated with ESS. RESULTS: ESS was correlated with age (r = -0.148, P <0.001), number of apnoeas (r = 0.096, P = 0.006), apnoea load (r = 0.102, P = 0.003), apnoea index (r = 0.075, P = 0.032), number of desaturations (r = 0.081, P = 0.020), minimum SpO2 (r = -0.071, P = 0.041), time SpO2 <85% (r = 0.075, P = 0.031) and REM sleep duration (r = 0.099, P = 0.004). Linear regression analysis found age (P <0.001), apnoea load (P = 0.005), REM (P = 0.021) and stage 1 sleep duration (P = 0.042) as independent factors correlated to ESS. The apnoea load calculated using duration in apnoea correlate with ESS in patients with severe OSA by AHI criteria compared to the mild category. CONCLUSION: AHI does not correlate with ESS. Younger age, longer apnoea, stage 1 and REM sleep were independently related to higher ESS though the correlations were weak. Apnoea load should be taken into account when determining OSA severity.

The Business Case for Investing in Physician Well-being.

Importance: Widespread burnout among physicians has been recognized for more than 2 decades. Extensive evidence indicates that physician burnout has important personal and professional consequences. Observations: A lack of awareness regarding the economic costs of physician burnout and uncertainty regarding what organizations can do to address the problem have been barriers to many organizations taking action. Although there is a strong moral and ethical case for organizations to address physician burnout, financial principles (eg, return on investment) can also be applied to determine the economic cost of burnout and guide appropriate investment to address the problem. The business case to address physician burnout is multifaceted and includes costs associated with turnover, lost revenue associated with decreased productivity, as well as financial risk and threats to the organization's long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety. Nearly all US health care organizations have used similar evidence to justify their investments in safety and quality. Herein, we provide conservative formulas based on readily available organizational characteristics to determine the financial return on organizational investments to reduce physician burnout. A model outlining the steps of the typical organization's journey to address this issue is presented. Critical ingredients to making progress include prioritization by leadership, physician involvement, organizational science/learning, metrics, structured interventions, open communication, and promoting culture change at the work unit, leader, and organization level. Conclusions and Relevance: Understanding the business case to reduce burnout and promote engagement as well as overcoming the misperception that nothing meaningful can be done are key steps for organizations to begin to take action. Evidence suggests that improvement is possible, investment is justified, and return on investment measurable. Addressing this issue is not only the organization's ethical responsibility, it is also the fiscally responsible one.

Laparoscopic cholecystectomy for acute cholecystitis: an analysis of early versus delayed cholecystectomy and predictive factors for conversion.

BACKGROUND: There is an increasing preference for early laparoscopic cholecystectomy (ELC) as compared to delayed LC (DLC) in the management of acute cholecystitis (AC). Conversion to open cholecystectomy (LOC) remains an important outcome. We aim to compare ELC and DLC outcomes and identify LOC predictors. METHODS: Retrospective analysis of 466 patients who underwent LC for AC from June 2010 to June 2015 was performed. Patients were divided into ELC and DLC groups, defined as LC performed within 7 days and between 4 to 24 weeks of symptom onset, respectively. Peri-operative outcomes and predictors for LOC were analyzed. RESULTS: Conversion rates were comparable [ELC, 8.6% vs. DLC, 8.0%] (P=0.867). While median operative time was longer in ELC (101.5 min [83.0-130.1]) than DLC (88.0 min [62.3-118.8]) (P<0.001), intraoperative (ELC, 1.9% vs. DLC, 3.0%; P=0.541) and postoperative morbidity (ELC, 13.5% vs. DLC, 12.5%; P=0.688) was comparable. Median total length of stay (LOS) was shorter in ELC (4 days [3-6]) than DLC (5 days [4-9]) (P<0.001). Univariate analysis showed increased age (LC, 57 [45-66] vs. LOC, 60 [56-72]; P=0.016), presence of comorbidities (LC, 69.0% vs. LOC, 87.8%; P=0.009), previous abdominal surgery (LC, 6.1% vs. LOC, 17.1%; P=0.014), fever (P=0.001), Murphy's sign (P=0.005) and lower albumin (LC, 42.0 [39.0-45.0] vs. LOC, 40.0 [36.0-43.0]; P=0.003) to be predictors for LOC. CONCLUSIONS: ELC provides shorter LOS and eliminates the risk of gallstone-related morbidity while awaiting surgery. It should be advocated for patients with AC. The presence of comorbidities, increased age, previous abdominal surgery and low albumin are predictors for conversion.

Delayed Presentation of Acute Cholecystitis: Comparative Outcomes of Same-Admission Versus Delayed Laparoscopic Cholecystectomy.

INTRODUCTION: Studies have shown that same-admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). However, no studies have compared both modalities in patients with delayed presentation. The aim of the study was to compare outcomes between SALC and DLC in AC patients with more than 7-day symptom duration. METHODS: A retrospective analysis of 83 AC patients who underwent LC after presenting with >7 days of symptoms from June 2010 to June 2015 was performed. Patients were divided into L-SALC and L-DLC, defined as LC performed within the same admission and between 4 and 24 weeks after discharge, respectively. Peri-operative outcomes were evaluated. RESULTS: In L-SALC patients, the intra-operative severity was higher (p < 0.001) and median operative time was longer (L-SALC, 107 min (46-220) vs L-DLC, 95 mins (25-186)) (p = 0.048). Conversion rates were also higher in L-SALC than that in L-DLC (L-SALC, 21.4% vs L-DLC, 4.9%) (p = 0.048). While post-operative morbidity was similar, L-SALC was associated with a longer post-operative length of stay as compared to L-DLC (L-SALC, 2 (1-17) vs L-DLC, 1 (1-6)) (p < 0.001). CONCLUSION: DLC provides lower conversion rates and shorter length of stay in AC patients presenting beyond 7 days of symptoms. This group of patients should be offered DLC.

Same admission laparoscopic cholecystectomy for acute cholecystitis: is the "golden 72 hours" rule still relevant?

BACKGROUND: Studies have shown that same admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy for acute cholecystitis (AC). While some proposed a"golden 72-hour" for SALC, the optimal timing remains controversial. The aim of the study was to compare the outcomes of SALC in AC patients with different time intervals from symptom onset. METHODS: A retrospective analysis of 311 patients who underwent SALC for AC from June 2010-June 2015 was performed. Patients were divided into three groups based on the time interval between symptom onset and surgery: <4 days (E-SALC), 4-7 days (M-SALC), >7 (L-SALC). RESULTS: The mean duration of symptoms was 2(1-3), 5(4-7) and 9 (8-13) days for E-SALC, M-SALC and L-SALC, respectively (p < 0.001). Conversion rates were higher in the L-SALC group [E-SALC, 8.2% vs M-SALC, 9.6% vs L-SALC, 21.4%] (p = 0.048). The total length of stay was longer in patients with longer symptom duration [E-SALC, 4 (2-33) vs M-SALC, 2 (2-23) vs L-SALC, 7 (2-49)] (p < 0.001). CONCLUSION: Patients with AC presenting beyond 7 days of symptoms have higher conversion rates and longer length of stay associated with SALC. However, patients with less than a week of symptoms should be offered SALC.

Exposure To Harmful Workplace Practices Could Account For Inequality In Life Spans Across Different Demographic Groups.

The existence of important socioeconomic disparities in health and mortality is a well-established fact. Many pathways have been adduced to explain inequality in life spans. In this article we examine one factor that has been somewhat neglected: People with different levels of education get sorted into jobs with different degrees of exposure to workplace attributes that contribute to poor health. We used General Social Survey data to estimate differential exposures to workplace conditions, results from a meta-analysis that estimated the effect of workplace conditions on mortality, and a model that permitted us to estimate the overall effects of workplace practices on health. We conclude that 10-38 percent of the difference in life expectancy across demographic groups can be explained by the different job conditions their members experience.

Genetic optimization of photonic bandgap structures.

We investigate the use of a Genetic Algorithm (GA) to design a set of photonic crystals (PCs) in one and two dimensions. Our flexible design methodology allows us to optimize PC structures for specific objectives. In this paper, we report the results of several such GA-based PC optimizations. We show that the GA performs well even in very complex design spaces, and therefore has great potential as a robust design tool in a range of PC applications.