Multivariable Cost Frontiers-Qualitative Financial Analyses Using Operational Metrics From the Implementation of a Surgery Fellowship.

OBJECTIVE: We expand the application of cost frontiers and introduce a novel approach using qualitative multivariable financial analyses. SUMMARY BACKGROUND DATA: With the creation of a 5 + 2-year fellowship program in July 2016, the Division of Vascular Surgery at the University of Vermont Medical Center altered the underlying operational structure of its inpatient services. METHOD: Using WiseOR (Palo Alto, CA), a web-based OR management data system, we extracted the operating room metrics before and after August 1, 2016 service for each 4-week period spanning from September 2015 to July 2017. The cost per minute modeled after Childers et al's inpatient OR cost guidelines was multiplied by the after-hours utilization to determine variable cost. Zones with corresponding cutoffs were used to graphically represent cost efficiency trends. RESULTS: Caseload/FTE for attending surgeons increased from 11.54 cases per month to 13.02 cases per month ( P = 0.0771). Monthly variable costs/FTE increased from $540.2 to $1873 ( P = 0.0138). Monthly revenue/FTE increased from $61,505 to $70,277 ( P = 0.2639). Adjusted monthly reve-nue/FTE increased from $60,965 to $68,403 ( P = 0.3374). Average monthly percent of adjusted revenue/FTE lost to variable costs increased from 0.85% to 2.77% ( P = 0.0078). Adjusted monthly revenue/case/FTE remained the same from $5309 to $5319 ( P = 0.9889). CONCLUSION: In summary, we demonstrate that multivariable cost (or performance) frontiers can track a net increase in profitability associated with fellowship implementation despite diminishing returns at higher caseloads.

Diagnosis and predicted outcomes of patients with cystic fibrosis related liver disease considered for lung transplantation.

INTRODUCTION: There is no gold standard criterion for the diagnosis of cystic fibrosis-related liver disease (CFRLD) and there is uncertainty over its impact on the outcome of lung transplantation. METHOD: Lung recipients (n = 238) were divided into two groups-CFRLD and non-CFRLD based on a modified aspartate aminotransferase-to-platelet ratio index (APRI) score (mAPRI) to diagnose CFRLD and predict severity of liver disease. Groups were compared to assess validity of the diagnosis and survival outcomes. RESULT: The new diagnostic criterion was effective at differentiating CFRLD from non-CFRLD. There was no significant difference in the survival between two groups at short, medium, or long term demonstrated by the Kaplan-Meier plot with survival of 85%, 73%, 47%, 18.6%, and 4.7% at 1, 2, 5, 10, and 15 years respectively. A mAPRI score of greater than .2 had a sensitivity of 43.0% but a specificity of 82.5 % for diagnosis of CFRLD and 46.5% sensitivity but 100% specificity in predicting an ultrasound/biopsy proven hepatic abnormality associated with CFRLD. CONCLUSION: A mAPRI sore is a highly specific non-invasive tool for diagnosis of CFRLD. Recipients with CFRLD but grossly preserved hepatocellular function have a similar outcome to patients without CFRLD.

COVID-19 and liver cancer: lost patients and larger tumours.

BACKGROUND: Northern England has been experiencing a persistent rise in the number of primary liver cancers, largely driven by an increasing incidence of hepatocellular carcinoma (HCC) secondary to alcohol-related liver disease and non-alcoholic fatty liver disease. Here we review the effect of the COVID-19 pandemic on primary liver cancer services and patients in our region. OBJECTIVE: To assess the impact of the COVID-19 pandemic on patients with newly diagnosed liver cancer in our region. DESIGN: We prospectively audited our service for the first year of the pandemic (March 2020-February 2021), comparing mode of presentation, disease stage, treatments and outcomes to a retrospective observational consecutive cohort immediately prepandemic (March 2019-February 2020). RESULTS: We observed a marked decrease in HCC referrals compared with previous years, falling from 190 confirmed new cases to 120 (37%). Symptomatic became the the most common mode of presentation, with fewer tumours detected by surveillance or incidentally (% surveillance/incidental/symptomatic; 34/42/24 prepandemic vs 27/33/40 in the pandemic, p=0.013). HCC tumour size was larger in the pandemic year (60±4.6 mm vs 48±2.6 mm, p=0.017), with a higher incidence of spontaneous tumour haemorrhage. The number of new cases of intrahepatic cholangiocarcinoma (ICC) fell only slightly, with symptomatic presentation typical. Patients received treatment appropriate for their cancer stage, with waiting times shorter for patients with HCC and unchanged for patients with ICC. Survival was associated with stage both before and during the pandemic. 9% acquired COVID-19 infection. CONCLUSION: The pandemic-associated reduction in referred patients in our region was attributed to the disruption of routine healthcare. For those referred, treatments and survival were appropriate for their stage at presentation. Non-referred or missing patients are expected to present with more advanced disease, with poorer outcomes. While protective measures are necessary during the pandemic, we recommend routine healthcare services continue, with patients encouraged to engage.

Análise comparativa de quedas e tempo de reação entre idosas sedentárias e praticantes de atividades físicas / Comparative analysis during falls and reaction time amongst sedentary and physycally active female elderly

No envelhecimento, ocorre diminuição de respostas a estímulos externos, o que pode acarretar quedas devido ao desequilíbrio postural da pessoa. Isso ocorre porque, nessa fase da vida, existe uma dificuldade em manter o corpo sobre sua base de apoio, seja ela estacionária ou móvel. O tempo de reação (TR) humano pode ser entendido como o tempo necessário para que uma pessoa perceba e reaja o mais rapidamente possível. Esse fenômeno pode ser chamado de reflexo e representa o nível de coordenação neuromuscular, em que os estímulos visuais, auditivos ou táteis são decodificados pelo corpo por meio de vários processos físicos, químicos e mecânicos. O objetivo deste trabalho é o seguinte: comparar o tempo de reação entre idosas que praticam atividade física ou não e confrontar o histórico de quedas com o tempo de reação das participantes, em ambos os grupos. Metodologia: trata-se de estudo quantitativo transversal, com 120 idosas, distribuídas em dois grupos, com idade entre 65 e 75 anos, praticantes de dança e não praticantes. Para a coleta dos dados, foi utilizada uma plataforma de contato e um questionário com o objetivo de identificar as quedas no ano. Os dados foram analisados estatisticamente pelo t student. Resultados: O grupo da dança apresentou menor TR e número de quedas em relação ao outro grupo. Conclusão: este estudo demonstrou que a atividade física, como a dança, diminuiu a possibilidade de queda em idosos(AU)

Reaction time (RT) is the ability to react with greater speed of movement, according to specific conditioning. With aging the responses to external stimuli decreases, which can lead to falls, the prevention of which are by postural balance maintenance, responding immediately to stimuli thus maintaining body position on its support base, whether stationary or mobile. The objective is to compare the reaction time among elderly women who practice physical activity or not, and to compare the history of falls with the reaction time of the participants, in both groups. Methodology: this was a cross-sectional study with a quantitative approach. The participants were 120 elderly women between 65 and 75 years of age, divided into two groups: dance practitioners and non practitioners of physical activities. A contact platform (Just Jump System, Probotics INC.) was used for RT data collection and for the data on the number of falls in the last twelve months a structured questionnaire was used. The data collected from RT were analyzed statistically by the t student, being considered significant values of p <0.05. Results: the dance group presented a lower RT in the tests compared to the other group, with p <0.0001 and lower number of falls in relation to G2 (G1 = 14 and G2 = 46). Conclusion: this study we believe may contribute to a decrease in hospitalization, because the improvement of the RT as a result of their training, will favor the elderly in their capacity of immediate response to the stimulus, reducing the possibility of falls.(AU)

Geo-epidemiology and environmental co-variate mapping of primary biliary cholangitis and primary sclerosing cholangitis.

BACKGROUND & AIMS: Autoimmune liver disease (AILD) is thought to result from a complex interplay between genetics and the environment. Studies to date have focussed on primary biliary cholangitis (PBC) and demonstrated higher disease prevalence in more urban, polluted, and socially deprived areas. This study utilises a large cohort of patients with PBC and primary sclerosing cholangitis (PSC) to investigate potential environmental contributors to disease and to explore whether the geo-epidemiology of PBC and PSC are disease-specific or pertain to cholestatic AILD in general. METHODS: All adult patients with PBC and PSC in a tightly defined geographical area within the UK were identified. Point- and area-based analyses and structural equation modelling (SEM) were used to investigate for disease clustering and examine for relationships between prevalence, distribution of environmental contaminants, and socio-economic status. RESULTS: We identified 2,150 patients with PBC and 472 with PSC. Significant spatial clustering was seen for each disease. A high prevalence of PBC was found in urban, post-industrial areas with a strong coal-mining heritage and increased environmental cadmium levels, whereas a high PSC prevalence was found in rural areas and inversely associated with social deprivation. CONCLUSIONS: This study demonstrates spatial clustering of PBC and PSC and adds to our understanding of potential environmental co-variates for both diseases. Disease clustering, within the same geographical area but over different scales, is confirmed for each disease with distinct risk profiles identified and associations with separate putative environmental factors and socio-economic status. This suggests that different triggers and alternative pathways determine phenotypic expression of autoimmunity in the affected population. Co-variate analysis points towards the existence of specific disease triggers. LAY SUMMARY: This study looked for potential environmental triggers in patients with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) living in the north-east of England and north Cumbria. We found that PBC was more common in urban areas with a history of coal mining and high levels of cadmium whereas PSC was more common in rural areas with lower levels of social deprivation.

The Model of Mortality with Incident Cirrhosis (MoMIC) and the model of Long-term Outlook of Mortality in Cirrhosis (LOMiC).

The purpose of this study was to produce two statistical survival models in those with cirrhosis utilising only routine parameters, including non-liver-related clinical factors that influence survival. The first model identified and utilised factors impacting short-term survival to 90-days post incident diagnosis, and a further model characterised factors that impacted survival following this acute phase. Data were from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. Incident cases in patients ≥18 years were identified between 1998 and 2014. Patients that had prior history of cancer or had received liver transplants prior were excluded. Model-1 used a logistic regression model to predict mortality. Model-2 used data from those patients who survived 90 days, and used an extension of the Cox regression model, adjusting for time-dependent covariables. At 90 days, 23% of patients had died. Overall median survival was 3.7 years. Model-1: numerous predictors, prior comorbidities and decompensating events were incorporated. All comorbidities contributed to increased odds of death, with renal disease having the largest adjusted odds ratio (OR = 3.35, 95%CI 2.97-3.77). Model-2: covariables included cumulative admissions for liver disease-related events and admissions for infections. Significant covariates were renal disease (adjusted hazard ratio (HR = 2.89, 2.47-3.38)), elevated bilirubin levels (aHR = 1.38, 1.26-1.51) and low sodium levels (aHR = 2.26, 1.84-2.78). An internal validation demonstrated reliability of both models. In conclusion: two survival models that included parameters commonly recorded in routine clinical practice were generated that reliably forecast the risk of death in patients with cirrhosis: in the acute, post diagnosis phase, and following this critical, 90 day phase. This has implications for practice and helps better forecast the risk of mortality from cirrhosis using routinely recorded parameters without inputs from specialists.

Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level.

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK.

This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.

Primary sclerosing cholangitis.

Primary sclerosing cholangitis is a rare, chronic cholestatic liver disease characterised by intrahepatic or extrahepatic stricturing, or both, with bile duct fibrosis. Inflammation and fibrosis of bile ducts and the liver are followed by impaired bile formation or flow and progressive liver dysfunction. Patients might be asymptomatic at presentation or might have pruritus, fatigue, right upper quadrant pain, recurrent cholangitis, or sequelae of portal hypertension. The key diagnostic elements are cholestatic liver biochemistry and bile duct stricturing on cholangiography. Genetic and environmental factors are important in the cause of the disease, with the intestinal microbiome increasingly thought to play a pathogenetic role. Approximately 70% of patients have concurrent inflammatory bowel disease and patients require colonoscopic screening and surveillance. Primary sclerosing cholangitis is associated with increased malignancy risk and surveillance strategies for early cholangiocarcinoma detection are limited. No single drug has been proven to improve transplant-free survival. Liver transplantation is effective for advanced disease but at least 25% of patients develop recurrent disease in the graft.

Impact of mode of failure and end-organ dysfunction on the survival of adult Fontan patients undergoing cardiac transplantation.

OBJECTIVES: Adults with failing Fontan circulation (FFC) represent a heterogeneous, high-risk group for cardiac transplantation with poor reported outcomes. We studied the impact of mode of Fontan failure (preserved versus impaired systolic ventricular function) and end-organ dysfunction on early survival in adults undergoing cardiac transplantation for FFC. METHODS: A single-centre, retrospective study of 26 adults (≥16 years) with FFC undergoing cardiac transplantation between 1990 and 2015. Patients were classified by the presence or absence of preserved systolic ventricular function (PVF). End-organ dysfunction was assessed by serum markers, including albumin, liver ultrasound and the presence of varices, ascites, splenomegaly and thrombocytopaenia (VAST score for portal hypertension). RESULTS: Thirty-day survival rate for the entire cohort was 69.2%, with 76.2% survival for the recent era. One-year Kaplan-Meier survival rate was 65.4%. Actuarial survival was poorer in those with PVF or heterotaxy (P = 0.01; log-rank test). Cox multivariable regression analysis confirmed PVF as an independent predictor for death (odds ratio, OR 5.38; confidence interval, CI 1.08-26.96; P = 0.04). In examining the PVF subset further, these patients had significantly higher VAST and liver ultrasound scores and lower serum albumin, compared with patients with impaired function. Patients with PVF and ≥moderate liver fibrosis on ultrasound or VAST score ≥2 accounted for two-thirds of the total mortality. CONCLUSIONS: Favourable cardiac transplantation outcomes can be achieved in adults with failing Fontan circulation. Patients with PVF may represent a distinct subset with more perturbed failing Fontan physiology and higher cardiac transplant mortality. We continue, however, to evolve and refine our strategies and are optimistic concerning future improvement in outcomes even in those with PVF.

Análise do tempo de reação e a correlação com quedas e seus danos em idosos / Analysis of reaction time and correlation with falls and their damage in the elderly

O tempo de reação é a capacidade de reagir com maior rapidez de movimento, de acordo com o condicionamento específico. Sabe-se que com envelhecimento ocorre diminuição das respostas aos estímulos externos podendo acarretar quedas, cuja prevenção se deve a manutenção do equilíbrio postural, o qual responde imediatamente aos estímulos visando manter a posição do corpo sobre sua base de apoio, seja ela estacionária ou móvel. O objetivo deste estudo foi verificar a importância da dança, atividade física que envolve tempo de reação, na prevenção de quedas em idosos. Metodologia: trata-se estudo transversal com abordagem quantitativa. Participaram 120 idosas com idades entre 65 e 75 anos, divididos em dois grupos: Praticante de dança regular e não praticantes de atividade física. Para a coleta dos dados foi utilizado o questionário avaliando Atividade Física e Queda; (AFQ) e para medição do tempo de reação foi utilizado a plataforma de contato (Just Jump System, Probotics INC.) visando medir tempo de reação. Os dados coletados foram analisados estatisticamente pelo teste t student, sendo considerados significantes os valores de p < 0,05. Resultados: O grupo que praticava regularmente a dança apresentou menor Tempo de Reação frente ao outro que não realizava atividade física, em comparação ao quantitativo de quedas apresentando significância p < 0,0001, demonstrando que teve maior número de quedas. Conclusão: Acreditamos que este estudo possa vir a contribuir para diminuição de hospitalização, pois com a melhora do tempo de reação proveniente do seu treinamento, favorecerá ao idoso, a capacidade de resposta imediata ao estímulo, reduzindo a possibilidade de quedas

Regional Anesthesia Is Cost-Effective in Preventing Unanticipated Hospital Admission in Pediatric Patients Having Anterior Cruciate Ligament Reconstruction.

BACKGROUND AND OBJECTIVES: Published studies have shown a benefit of regional anesthesia (RA) in preventing unplanned hospital admissions (UHAs) and decreasing hospital costs after orthopedic surgeries in adults but not pediatric patients. We performed a retrospective analysis to assess the effect of converting from an opioid to RA-based approach to pain management after pediatric anterior cruciate ligament (ACL) reconstruction. METHODS: The records of patients having ACL reconstruction were reviewed. Two groups, those with (n = 115) and without (n = 39) nerve blocks, were identified. Single-shot blocks or indwelling catheters were performed in the operating room (OR) or a block room. Time to discharge readiness, postoperative opiate and antiemetic consumption, hospital admission or discharge, and complications were recorded. The cost of providing RA, the change in UHA and postanesthesia care unit utilization, and subsequent financial impact were calculated. RESULTS: Regional anesthesia-based pain management was associated with a lower rate of UHA (P = 0.045), less time in postanesthesia care unit phase II (P = 0.013), and a reduction in opioid consumption (P < 0.001). Use of a dedicated RA team with a dedicated block room resulted in cost savings or neutrality, whereas RA catheters placed in the OR were associated with increased direct hospital costs. CONCLUSIONS: Regional anesthesia for pain after ACL repair in pediatric patients facilitated reliable same-day surgery discharge and significantly reduced UHAs. Single-shot blocks and blocks performed outside the OR were the most cost-effective. In addition, nerve block patients required less opioids and were ready for discharge sooner.

Intracellular LINGO-1 negatively regulates Trk neurotrophin receptor signaling.

Neurotrophins, essential regulators of many aspects of neuronal differentiation and function, signal via four receptors, p75, TrkA, TrkB and TrkC. The three Trk paralogs are members of the LIG superfamily of membrane proteins, which share extracellular domains consisting of leucine-rich repeat and C2 Ig domains. Another LIG protein, LINGO-1 has been reported to bind and influence signaling of p75 as well as TrkA, TrkB and TrkC. Here we examine the manner in which LINGO-1 influences the function of TrkA, TrkB and TrkC. We report that Trk activation promotes Trk association with LINGO-1, and that this association promotes Trk degradation by a lysosomal mechanism. This mechanism resembles the mechanism by which another LIG protein, LRIG1, promotes lysosomal degradation of receptor tyrosine kinases such as the EGF receptor. We present evidence indicating that the Trk/LINGO-1 interaction occurs, in part, within recycling endosomes. We show that a mutant form of LINGO-1, with much of the extracellular domain deleted, has the capacity to enhance TrkA signaling in PC12 cells, possibly by acting as an inhibitor of Trk down-regulation by full length LINGO-1. We propose that LINGO-1 functions as a negative feedback regulator of signaling by cognate receptor tyrosine kinases including TrkA, TrkB and TrkC.

Fontan-associated liver disease: Implications for heart transplantation.

Chronic liver diseases are associated with multiple complications, including cirrhosis, portal hypertension, ascites, synthetic dysfunction and hepatocellular carcinoma, and these processes are increasingly recognized in post-Fontan patients. Fontan-associated liver disease (FALD) can be defined as abnormalities in liver structure and function that result from the Fontan circulation and are not related to another disease process. FALD arises due to chronic congestion of the liver created by the elevated venous pressure and low cardiac output of the Fontan circulation, which may be superimposed on previous liver injury. Pathology studies have generally shown that FALD worsens as time post-Fontan increases, but the prevalence of FALD is not well defined because the majority of Fontan patients, even those with significant hepatic fibrosis, appear to be asymptomatic and biochemical or functional hepatic abnormalities are usually subtle or absent. Alternate non-invasive investigations, derived from the study of other chronic liver diseases, have been tested in small series of pediatric and adult Fontan patients, but they have been confounded by congestion and do not correlate well with liver biopsy findings. Liver disease can complicate Fontan circulatory failure and may even be significant enough to be considered a contraindication to heart transplantation or require combined heart-liver transplantation. The search for the optimal management strategy continues in the setting of increasing numbers of Fontan patients surviving to adulthood and being referred for heart transplantation. Thus, in this review we attempt to define the scope and significance of FALD and address transplant-related assessment and management of this challenging disorder.

A Department-of-Anesthesiology-based management protocol for perioperative corneal abrasions.

INTRODUCTION: Corneal abrasions (CAs) are the most prevalent ocular injuries in the perioperative period. Previously, patients at our community hospital would wait for an ophthalmologist to be available to manage these minor injuries. To decrease this waiting period - and thereby increase patient satisfaction - we developed an anesthesiology-based protocol to manage minor CAs arising in the recovery room. The current study sought to assess this protocol's efficacy as well as further establish the incidence and some risk factors of CA. METHODS: This was a hospital-based, observational study. As per protocol, anesthesiologists saw and diagnosed any patient exhibiting symptoms of CA, after which they initiated a preestablished treatment regimen. To examine the efficacy of this protocol between March 2007 and December 2011, the number of CAs anesthesiologists managed and time to treatment were recorded. Additionally, the frequency of CAs was established along with some of their risk factors. RESULTS: Throughout the study period, there were 91,064 surgical cases, with 118 CAs (0.13% incidence). Anesthesiology alone managed 110 (93.22%) of these cases. The median time between the end of anesthesia to the time of prescribed ophthalmic medication was 156 minutes (first-third interquartile range: 108-219). All patients experienced resolution of symptoms by the morning following their complaint. Compared to the general surgical population, CA patients were older (P<0.01) and underwent longer surgeries (P<0.01). CONCLUSION: Minor CAs can be safely and effectively managed using an anesthesiology-based approach. Advanced age and longer surgery are confirmed as risk factors for these injuries.