Time-Driven Activity-Based Costing in Emergency Medicine.

Value in emergency medicine is determined by both patient-important outcomes and the costs associated with achieving them. However, measuring true costs is challenging. Without an understanding of costs, emergency department (ED) leaders will be unable to determine which interventions might improve value for their patients. Although ongoing research may determine which outcomes are meaningful, an accurate costing system is also needed. This article reviews current costing mechanisms in the ED and their pitfalls. It then describes how time-driven activity-based costing may be superior to these current costing systems. Time-driven activity-based costing, in addition to being a more accurate costing system, can be used for process improvements in the ED.

Associations between preoperative functional status and functional outcomes of total joint replacement in the Dominican Republic.

OBJECTIVE: In developed countries, the functional status scores of patients with poor preoperative scores undergoing total joint replacement (TJR) improve more following TJR than those for patients with better preoperative scores. However, those with better preoperative scores achieve the best postoperative functional outcomes. We determined whether similar associations exist in a developing country. METHODS: Dominican patients undergoing total hip or knee replacement completed WOMAC and SF-36 surveys preoperatively and at 12-month follow-up. Patients were stratified into low-, medium- and high-scoring preoperative groups based on their preoperative WOMAC function scores. We examined the associations between the baseline functional status of these groups and two outcomes-improvement in functional status over 12 months and functional status at 12 months-using analysis of variance with multivariable linear regression. RESULTS: Patients who scored the lowest preoperatively made the greatest gains in function and pain relief following their TJRs. However, there were no significant differences in pain or function at 12-month follow-up between patients who scored low and those who scored high on preoperative WOMAC and SF-36 surveys. CONCLUSION: Patients with poor preoperative functional status had greater improvement but similar 12-month functional outcomes compared with patients who had a higher level of function before surgery. These results suggest that a policy of focusing scarce resources on patients with worse functional status in developing countries may optimize improvement following TJR without threatening functional outcome. Additional research is needed to confirm these findings in other developing countries and to understand why these associations vary between patients in the Dominican Republic and patients from developed countries.

Enhancing the quality of international orthopedic medical mission trips using the blue distinction criteria for knee and hip replacement centers.

BACKGROUND: Several organizations seek to address the growing burden of arthritis in developing countries by providing total joint replacements (TJR) to patients with advanced arthritis who otherwise would not have access to these procedures. Because these mission trips operate in resource poor environments, some of the features typically associated with high quality care may be difficult to implement. In the U.S., many hospitals that perform TJRs use the Blue Cross/Shield's Blue Distinction criteria as benchmarks of high quality care. Although these criteria were designed for use in the U.S., we applied them to Operation Walk (Op-Walk) Boston's medical mission trip to the Dominican Republic. Evaluating the program using these criteria illustrated that the program provides high quality care and, more importantly, helped the program to find areas of improvement. METHODS: We used the Blue Distinction criteria to determine if Op-Walk Boston achieves Blue Distinction. Each criterion was grouped according to the four categories included in the Blue Distinction criteria--"general and administrative", "structure", "process", or "outcomes and volume". Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. Of the non-replicated criteria, Op-Walk Boston's clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion. RESULTS: Out of 100 possible points, the program received 71, exceeding the 60-point threshold needed to qualify as a Blue Distinction center. The program met five out of eight "required" criteria and 11 out of 19 "informational" criteria. It scored 14/27 in the "general" category, 30/36 in the "structure" category, 17/20 in the "process" category, and 10/17 in the "outcomes and volume" category. CONCLUSION: Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries.

Revision hip arthroplasty with a modular cementless stem: mid-term follow up.

Despite the increasing volume of revision total hip arthroplasty (THA) being performed in the United States, there are few studies reporting mid-term clinical and radiographic outcomes of modular fully porous-coated femoral stems. We retrospectively studied a consecutive series of patients who underwent revision THA with a modular extensively porous-coated femoral component at a single institution and by a single surgeon. The final study group included 54 hips (52 patients) followed for an average of 84 months. Ten-year survival rates with revision for any reason and revision for femoral loosening as endpoints were 94% and 100%, respectively. No complications regarding the modular junction were encountered. Of the 50 hips with adequate radiographs, all showed proximal ingrowth and 42 (84%) had both proximal and distal ingrowth. The modular, fully porous-coated femoral stem studied demonstrated excellent survivorship and bone ingrowth at mid-term follow up.

A genome-wide screen identifies genes that affect somatic homolog pairing in Drosophila.

In Drosophila and other Dipterans, homologous chromosomes are in close contact in virtually all nuclei, a phenomenon known as somatic homolog pairing. Although homolog pairing has been recognized for over a century, relatively little is known about its regulation. We performed a genome-wide RNAi-based screen that monitored the X-specific localization of the male-specific lethal (MSL) complex, and we identified 59 candidate genes whose knockdown via RNAi causes a change in the pattern of MSL staining that is consistent with a disruption of X-chromosomal homolog pairing. Using DNA fluorescent in situ hybridization (FISH), we confirmed that knockdown of 17 of these genes has a dramatic effect on pairing of the 359 bp repeat at the base of the X. Furthermore, dsRNAs targeting Pr-set7, which encodes an H4K20 methyltransferase, cause a modest disruption in somatic homolog pairing. Consistent with our results in cultured cells, a classical mutation in one of the strongest candidate genes, pebble (pbl), causes a decrease in somatic homolog pairing in developing embryos. Interestingly, many of the genes identified by our screen have known roles in diverse cell-cycle events, suggesting an important link between somatic homolog pairing and the choreography of chromosomes during the cell cycle.