Cost-effectiveness of tenecteplase versus alteplase for stroke thrombolysis evaluation trial in the ambulance.

BACKGROUND: Tenecteplase administered to patients with ischaemic stroke in a mobile stroke unit (MSU) has been shown to reduce the perfusion lesion volumes and result in ultra-early recovery. We now seek to assess the cost-effectiveness of tenecteplase in the MSU. METHODS: A within-trial (TASTE-A) economic analysis and a model-based long-term cost-effectiveness analysis were performed. This post hoc within-trial economic analysis utilised the patient-level data (intention to treat, ITT) prospectively collected over the trial to calculate the difference in both healthcare costs and quality-adjusted life years (QALYs, estimated from modified Rankin scale score). A Markov microsimulation model was developed to simulate the long-term costs and benefits. RESULTS: In total, there were 104 patients with ischaemic stroke randomised to tenecteplase (n = 55) or alteplase (n = 49) treatment groups, respectively in the TASTE-A trial. The ITT-based analysis showed that treatment with tenecteplase was associated with non-signficantly lower costs (A$28,903 vs A$40,150 (p = 0.056)) and greater benefits (0.171 vs 0.158 (p = 0.457)) than that for the alteplase group over the first 90 days post the index stroke. The long-term model showed that tenecteplase led to greater savings in costs (-A$18,610) and more health benefits (0.47 QALY or 0.31 LY gains). Tenecteplase-treated patients had reduced costs for rehospitalisation (-A$1464), nursing home care (-A$16,767) and nonmedical care (-A$620) per patient. CONCLUSIONS: Treatment of ischaemic stroke patients with tenecteplase appeared to be cost-effective and improve QALYs in the MSU setting based on Phase II data. The reduced total cost from tenecteplase was driven by savings from acute hospitalisation and reduce need for nursing home care.

Long-Term Cost-Effectiveness of Severity-Based Triaging for Large Vessel Occlusion Stroke.

Background and Purpose: Pre-hospital severity-based triaging using the Ambulance Clinical Triage For Acute Stroke Treatment (ACT-FAST) algorithm has been demonstrated to substantially reduce time to endovascular thrombectomy in Melbourne, Australia. We aimed to model the cost-effectiveness of an ACT-FAST bypass system from the healthcare system perspective. Methods: A simulation model was developed to estimate the long-term costs and health benefits associated with diagnostic accuracy of the ACT-FAST algorithm. Three-month post stroke functional outcome was projected to the lifetime horizon to estimate the long-term cost-effectiveness between two strategies (ACT-FAST vs. standard care pathways). For ACT-FAST screened true positives (i.e., screened positive and eligible for EVT), a 52 mins time saving was applied unanimously to the onset to arterial time for EVT, while 10 mins delay in thrombolysis was applied for false-positive (i.e., screened positive but was ineligible for EVT) thrombolysis-eligible infarction. Quality-adjusted life year (QALY) was employed as the outcome measure to calculate the incremental cost-effectiveness ratio (ICER) between the ACT-FAST algorithm and the current standard care pathway. Results: Over the lifetime, ACT-FAST was associated with lower costs (-$45) and greater QALY gains (0.006) compared to the current standard care pathway, resulting in it being the dominant strategy (less costly but more health benefits). Implementing ACT-FAST triaging led to higher proportion of patients received EVT procedure (30 more additional EVT performed per 10,000 patients). The total Net Monetary Benefit from ACT-FAST care estimated at A$0.76 million based on its implementation for a single year. Conclusions: An ACT-FAST severity-triaging strategy is associated with cost-saving and increased benefits when compared to standard care pathways. Implementing ACT-FAST triaging increased the proportion of patients who received EVT procedure due to more patients arriving at EVT-capable hospitals within the 6-h time window (when imaging selection is less rigorous).

Cost-Effectiveness of Tenecteplase Before Thrombectomy for Ischemic Stroke.

BACKGROUND AND PURPOSE: Tenecteplase improved functional outcomes and reduced the requirement for endovascular thrombectomy in ischemic stroke patients with large vessel occlusion in the EXTEND-IA TNK randomized trial. We assessed the cost-effectiveness of tenecteplase versus alteplase in this trial. METHODS: Post hoc within-trial economic analysis included costs of index emergency department and inpatient stroke hospitalization, rehabilitation/subacute care, and rehospitalization due to stroke within 90 days. Sources for cost included key study site complemented by published literature and government websites. Quality-adjusted life-years were estimated using utility scores derived from the modified Rankin Scale score at 90 days. Long-term modeled cost-effectiveness analysis used a Markov model with 7 health states corresponding to 7 modified Rankin Scale scores. Probabilistic sensitivity analyses were performed. RESULTS: Within the 202 patients in the randomized controlled trial, total cost was nonsignificantly lower in the tenecteplase-treated patients (40 997 Australian dollars [AUD]) compared with alteplase-treated patients (46 188 AUD) for the first 90 days(P=0.125). Tenecteplase was the dominant treatment strategy in the short term, with similar cost (5412 AUD [95% CI, -13 348 to 2523]; P=0.181) and higher benefits (0.099 quality-adjusted life-years [95% CI, 0.001-0.1967]; P=0.048), with a 97.4% probability of being cost-effective. In the long-term, tenecteplase was associated with less additional lifetime cost (96 357 versus 106 304 AUD) and greater benefits (quality-adjusted life-years, 7.77 versus 6.48), and had a 100% probability of being cost-effective. Both deterministic sensitivity analysis and probabilistic sensitivity analyses yielded similar results. CONCLUSIONS: Both within-trial and long-term economic analyses showed that tenecteplase was highly likely to be cost-effective for patients with acute stroke before thrombectomy. Recommending the use of tenecteplase over alteplase could lead to a cost saving to the healthcare system both in the short and long term. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02388061.

Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing.

BACKGROUND: Telehealth interventions offer an evidenced-based approach to providing cost-effective care, education, and timely communication at a distance. Yet, despite its widespread use, telehealth has not reached full potential, especially in rural areas, due to the complex process of designing and implementing telehealth programs. The objective of this paper is to explore the use of a theory-based approach, the Model for Developing Complex Interventions in Nursing, to design a pilot telehealth intervention program for a rural population with multiple chronic conditions. METHODS: In order to develop a robust, evidenced based intervention that suits the needs of the community, stakeholders, and healthcare agencies involved, a design team comprised of state representatives, telehealth experts, and patient advocates was convened. Each design team meeting was guided by major model constructs (i.e., problem identification, defining the target population and objectives, measurement theory selection, building and planning the intervention protocol). Overarching the process was a review of the literature to ensure that the developed intervention was congruent with evidence-based practice and underlying the entire process was scope of practice considerations. RESULTS: Ten design team meetings were held over a six-month period. An adaptive pilot intervention targeting home and community-based Medicaid Waiver Program participants in a rural environment with a primary objective of preventing re-institutionalizations was developed and accepted for implementation. To promote intervention effectiveness, asynchronous (i.e., remote patient monitoring) and synchronous (i.e., nursing assessment of pain and mental health and care coordination) telehealth approaches were selected to address the multiple comorbidities of the target population. An economic evaluation plan was developed and included in the pilot program to assess intervention cost efficiency. CONCLUSIONS: The Model for Developing Complex Interventions in Nursing provided a simple, structured process for designing a multifaceted telehealth intervention to minimize re-institutionalization of participants with multiple chronic conditions. This structured process may promote efficient development of other complex telehealth interventions in time and resource constrained settings. This paper provides detailed examples of how the model was operationalized.

Emergency department visits coded for swimming pool diving injuries.

Despite legislative efforts to enhance safety in public swimming pools, diving injuries are still common. This study investigated the characteristics of emergency departments (EDs) visits for diving accidents. This study utilized 2006-2014 data from the Nationwide Emergency Department Sample and examined visits for accidents due to diving or jumping into water (swimming pool). Data were stratified by age categories. Over 83,000 ED visits were found and the majority of visits were by males. Significantly more patients were in the 15-24 age category. The majority of patients were discharged and were covered by private insurance. Total charges for the six-year period approached $620 million. Spinal cord injuries were more common in those over age 25, whereas intracranial injuries occurred more frequently in younger patients. This study provides a profile of patients presenting to US EDs for diving-related injuries.

Emergency department visits by pediatric patients sustained as a passenger on a motorcycle.

OBJECTIVE: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle. METHODS: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges. RESULTS: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries. CONCLUSION: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.

Intimate partner violence-related hospitalizations in Appalachia and the non-Appalachian United States.

The highly rural region of Appalachia faces considerable socioeconomic disadvantage and health disparities that are recognized risk factors for intimate partner violence (IPV). The objective of this study was to estimate the rate of IPV-related hospitalizations in Appalachia and the non-Appalachian United States for 2007-2011 and compare hospitalizations in each region by clinical and sociodemographic factors. Data on IPV-related hospitalizations were extracted from the State Inpatient Databases, which are part of the Healthcare Cost and Utilization Project. Hospitalization day, year, in-hospital mortality, length of stay, average and total hospital charges, sex, age, payer, urban-rural location, income, diagnoses and procedures were compared between Appalachian and non-Appalachian counties. Poisson regression models were constructed to test differences in the rate of IPV-related hospitalizations between both regions. From 2007-2011, there were 7,385 hospitalizations related to IPV, with one-third (2,645) occurring in Appalachia. After adjusting for age and rurality, Appalachian counties had a 22% higher hospitalization rate than non-Appalachian counties (ARR = 1.22, 95% CI: 1.14-1.31). Appalachian residents may be at increased risk for IPV and associated conditions. Exploring disparities in healthcare utilization and costs associated with IPV in Appalachia is critical for the development of programs to effectively target the needs of this population.

Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

BACKGROUND: Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. METHODS: Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). RESULTS: There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. CONCLUSION: Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. CLINICAL TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).

Emergency department visits by pediatric patients for poisoning by prescription opioids.

BACKGROUND: Prescription medication abuse is an increasingly recognized problem in the United States. As more opioids are being prescribed and abused by adults, there is an increased risk of both accidental and intentional exposure to children and adolescents. The impact of pediatric exposures to prescription pain pills has not been well studied. OBJECTIVES: We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. METHODS: This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2012. RESULTS: There were 21,928 pediatric ED visits for prescription opioid poisonings and more than half were unintentional. There was a bimodal age distribution of patients, with slightly more than half occurring in females. The majority of patients were discharged from the ED. More visits in the younger age group (0-5 years) were unintentional, while the majority of visits in the adolescent age group (15-17 years) were intentional. Mean charge per discharge was $1,840 and $14,235 for admissions and surmounted to over $81 million in total charges. CONCLUSION: Poisonings by prescription opioids largely impact both young children and adolescents. These findings can be used to help target this population for future preventive efforts.

Visits by the elderly to United States EDs for alcohol-related disorders.

OBJECTIVES: The objectives are to estimate the number of elderly patients presenting to emergency departments (EDs) in the United States from 2006 to 2011 for alcohol-related disorders and examine their demographic and clinical features. METHODS: This study used 2006 to 2011 data from the Nationwide ED Sample, a stratified, multistage sample designed to give national estimates of US ED visits each year. Clinical Classifications Software 660 code ("alcohol-related disorders") was used. The clinical and demographic features that were examined were as follows: number of admissions, disposition, sex, age, expected payer, income, geographic region, charges, and primary diagnoses and procedures performed. RESULTS: From 2006 to 2011, there were 1620345 ED visits for alcohol-related disorders in elderly patients. Roughly one-third were discharged from the ED, whereas 66% (1078677) were admitted to the hospital. Approximately 73% were male, and the mean age was 73 years. Most patients used Medicare (84%), resided in neighborhoods with the lowest median income national quartile (29%), and lived in the South (36.4%). The average charge for discharged patients was $4274.95 (4050.30-4499.61) and $37857.20 (36813.00-38901.40) for admitted patients. The total charges for all patients treated and released from the ED were $2166082965.40 and admitted was $40835690924.40. CONCLUSIONS: This study provided insight not only into the sociodemographic characteristics of this patient population but also the health care costs related to alcohol-related ED visits. These results may contribute to the development of future interventions targeted toward this population.

United States emergency department visits coded for intimate partner violence.

BACKGROUND: Limited information exists about medical treatment for victims of intimate partner violence (IPV). OBJECTIVE: Our aim was to estimate the number of emergency department (ED) visits and subsequent hospitalizations that were assigned a code specific to IPV and to describe the clinical and sociodemographic features of this population. METHODS: Data from the Nationwide Emergency Department Sample from 2006-2009 were analyzed. Cases with an external cause of injury code of E967.3 (battering by spouse or partner) were abstracted. RESULTS: From 2006-2009, there were 112,664 visits made to United States EDs with an e-code for battering by a partner or spouse. Most patients were female (93%) with a mean age of 35 years. Patients were significantly more likely to reside in communities with the lowest median income quartile and in the Southern United States. Approximately 5% of visits resulted in hospital admission. The mean charge for treat-and-release visits was $1904.69 and $27,068.00 for hospitalizations. Common diagnoses included superficial injuries and contusions, skull/face fractures, and complications of pregnancy. Females were more likely to experience superficial injuries and contusions, and males were more likely to have open wounds of the head, neck, trunk, and extremities. CONCLUSIONS: From 2006 to 2009, there were approximately 28,000 ED visits per year with an e-code specific to IPV. Although a minority, 7% of these visits were made by males, which has not been reported previously. Future prospective research should confirm the unique demographic and geographic features of these visits to guide development of targeted screening and intervention strategies to mitigate IPV and further characterize male IPV visits.

Testing devices for the prevention and treatment of stroke and its complications.

We are entering a challenging but exciting period when many new interventions may appear for stroke based on the use of devices. Hopefully these will lead to improved outcomes at a cost that can be afforded in most parts of the world. Nevertheless, it is vital that lessons are learnt from failures in the development of pharmacological interventions (and from some early device studies), including inadequate preclinical testing, suboptimal trial design and analysis, and underpowered studies. The device industry is far more disparate than that seen for pharmaceuticals; companies are very variable in size and experience in stroke, and are developing interventions across a wide range of stroke treatment and prevention. It is vital that companies work together where sales and marketing are not involved, including in understanding basic stroke mechanisms, prospective systematic reviews, and education of physicians. Where possible, industry and academics should also work closely together to ensure trials are designed to be relevant to patient care and outcomes. Additionally, regulation of the device industry lags behind that for pharmaceuticals, and it is critical that new interventions are shown to be safe and effective rather than just feasible. Phase IV postmarketing surveillance studies will also be needed to ensure that devices are safe when used in the 'real-world' and to pick up uncommon adverse events.

Trauma patient access: the role of the emergency medical services system in North-Central West Virginia.

UNLABELLED: Trauma patients face many obstacles as they access the healthcare system in North-Central West Virginia. This study highlights some of these barriers and discusses administrative and legislative initiatives that could help mitigate the disparities that rural trauma patients face. METHODS: This is a retrospective, observational study utilizing information from the West Virginia University (WVU) MedCom Database. Trauma related Emergency Medical Services (EMS) calls from 2002 to 2011 were reviewed to determine many of the parameters of the care provided by EMS in the WVU MedCom catchment area. These 54,952 trauma related EMS contacts were reviewed to determine estimated time of arrival (ETA) at the receiving facility, level of EMS response, trauma activation criteria, time of day, and day of week of the transport. RESULTS: The mean ETA for all transports was 11.7 minutes with mean transport ETA from the most rural county, Pendleton County, being 28.4 minutes. Emergency Medical Technician-B (BLS) providers covered 23% of the calls. Emergency Medical Technician-P (ALS) providers covered 76% of the calls. West Virginia State Trauma activation criteria were met for 30% of the transports. BLS providers transported 19% of these trauma activation criteria patients and ALS providers transported 78% of these transports. CONCLUSIONS: In north-central West Virginia, there are many barriers facing the trauma patient as they access the healthcare system. Among these are extended transport times, the capabilities of the EMS provider responding, and the limitation that approximately 50% of counties have either no hospital at all or only a hospital with limited treatment capability for the trauma patient transported by EMS.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke: experience from Australian stroke center.

BACKGROUND AND PURPOSE: Previous economic studies outside Australia have demonstrated that patients treated with tissue-type plasminogen activator (tPA) within 4.5 hours of stroke onset have lower healthcare costs than those not. We aim to perform cost-effectiveness analysis of intravenous tPA in an Australian setting. METHODS: Data on clinical outcomes and costs were derived for 378 patients who received intravenous tPA within 4.5 hours of stroke onset at Royal Melbourne Hospital (Australia) between January 2003 and December 2011. To simulate clinical outcomes and costs for a hypothetical control group assumed not to have received tPA, we applied efficacy data from a meta-analysis of randomized trials to outcomes observed in the tPA group. During a 1-year time-horizon, net costs, years of life lived, and quality-adjusted life-years were compared and incremental cost-effectiveness ratios derived for tPA versus no tPA. RESULTS: In the study population, mean (SD) age was 68.2 (13.5) years and 206 (54.5%) were men. Median National Institutes of Health Stroke Scale score (interquartile range) at presentation was 12.5 (8-18). Compared with no tPA, we estimated that tPA would result in 0.02 life-years and 0.04 quality-adjusted life-years saved per person>1 year. The net cost of tPA was AUD $55.61 per patient. The incremental cost-effectiveness ratios were AUD $2377 per life-year saved and AUD $1478 per quality-adjusted life-years saved. Because the costs of tPA are incurred only once, the incremental cost-effectiveness ratios would decrease with increasing time-horizon. Uncertainty analyses indicated the results to be robust. CONCLUSIONS: Intravenous tPA within 4.5 hours represents a cost-effective intervention for acute ischemic stroke.

Pediatric visits to United States Emergency Departments for alcohol-related disorders.

BACKGROUND: The use of alcohol by pediatric patients has not been thoroughly examined in the United States (US). Patients with complaints related to alcohol use frequently present to the Emergency Department initially. OBJECTIVE: Our aim was to determine the number of pediatric patients (ages 17 years and younger) presenting to Emergency Departments (EDs) in the US from 2006 to 2008 for alcohol-related disorders and examine selected clinical and demographic features of this population. METHODS: This was a retrospective cohort study using 3 years (2006-2008) of data from the Nationwide Emergency Department Sample. This database was used to identify patients younger than 18 years of age with an alcohol-related ED visit, and clinical and demographic features were examined. RESULTS: From 2006 to 2008, a total of 218,514 pediatric patients presented to US EDs and received a subsequent diagnosis of an alcohol-related disorder. Mean age of patients was 15.61 years. Most patients were male and tended to be from higher-income communities. CONCLUSIONS: There were 218,514 visits to US EDs by patients younger than 18 years of age for alcohol-related disorders, accounting for >$850 million dollars in charges. ED-based brief alcohol interventions shown to work in adult populations should be explored for use in pediatric patients.

Thrombolysis in the developing world: is there a role for streptokinase?

Intravenous thrombolysis with tissue plasminogen activator is the only proven acute therapy for ischemic stroke. This therapy has not been translated into clinical practice in the developing world primarily due to economic constraints. Streptokinase, a lower cost alternative thrombolytic agent, is widely available in developing countries where it is utilized to treat patients with acute coronary syndromes. Although this drug has previously been found to be ineffective in ischemic stroke, the lack of benefit may have been related to a number of factors related to trial design rather than the drug itself. Specific features of prior trial designs that may have adversely affected outcomes include a prolonged treatment window, inclusion of patients with established infarction on computed tomography scan, failure to treat excessive arterial pressures, a fixed dose of streptokinase, and concomitant use of antithrombotic medications. Given the lack of therapeutic alternatives in developing countries, a new trial of streptokinase in acute stroke, utilizing stricter inclusion criteria similar to those in more recent thrombolytic studies, appears warranted.

Visual assessment of perfusion-diffusion mismatch is inadequate to select patients for thrombolysis.

BACKGROUND: For MR perfusion-diffusion mismatch to be clinically useful as a means of selecting patients for thrombolysis, it needs to occur in real time at the MRI console. Visual mismatch assessment has been used clinically and in trials but has not been systematically validated. We compared the accuracy of visually rating console-generated images with offline volumetric measurements using data from the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET). METHODS: Perfusion time-to-peak (TTP) and diffusion-weighted images (DWI) (as generated by commercial MRI console software) and T(max) perfusion maps (which required offline calculation) were visually rated. Perfusion-diffusion mismatch, defined as a ratio of perfusion:diffusion lesion volume of >1.2, was independently scored by 1 expert and 2 inexperienced raters blinded to calculated volumes and clinical information. Visual mismatch was compared with region-of-interest-based volumetric calculation, which was used as the gold standard. RESULTS: Volumetric calculation demonstrated perfusion-diffusion mismatch in 85/99 patients. Visual TTP-DWI mismatch was correctly classified by the experienced rater in 82% of the cases (sensitivity: 0.86; specificity: 0.54) compared to 73% for the inexperienced raters (sensitivity: 0.75; specificity: 0.57). The interrater reliability for TTP-DWI mismatch was moderate (kappa = 0.50). Visual T(max)-DWI mismatch performed better (agreement - 93 and 87%, sensitivity - 95 and 88%, specificity - 77 and 82% for the experienced and inexperienced raters, respectively). CONCLUSIONS: The assessment of visual TTP-DWI mismatch at the MRI console is insufficiently reliable for use in clinical trials. Differences in perfusion analysis technique and visual inaccuracies combine to make visual TTP-DWI mismatch substantially different to volumetric T(max)-DWI mismatch. Automated software that applies perfusion thresholds may improve the reproducibility of real-time mismatch assessment.

Emergency department workload increase: dependence on primary care?

BACKGROUND: Increasing demand for emergency care and crowded emergency departments (EDs) lead some planners to conclude that inconvenient primary care scheduling increases the number of "unnecessary" ED visits. The reasons that the planners argue for more primary care are: to increase funding for primary care; the unfounded notion that it is less expensive to see a primary care physician (PCP) than an Emergency Physician; and the impractical goal that the ED should be used only by intellectually interesting life- or limb-threatened patients or "true emergencies." OBJECTIVE: To explore the rates of patient-reported access to primary care in ambulatory presentations to a rural tertiary care ED. METHODS: An observational study was performed in which an anonymous survey was given to a convenience sample of patients who presented by walking into the ED. RESULTS: Overall, 70.4% (686/975) of respondents stated that they had a PCP, and 38.1 % (252/661) of the sample had attempted to contact their physicians before presenting to the ED. Of the group who attempted to contact their physicians, 62.8% (130) were neither spoken to nor seen by any doctor. These rates did not change by time of presentation or by day of the week. CONCLUSION: The results suggest that it is neither a lack of primary care, nor the time of day or night that drives patients to come to the ED.