Social Support Assets and Needs of Underrepresented Students Participating in Health Sciences Pathways Programs in Birmingham, Alabama.

BACKGROUND: Using the Asset Bundle Model, we sought to understand the social support assets and needs of underrepresented minority (URM) high school, undergraduate, and graduate students. SETTING: Study participants were or had participated in health sciences pathway programs at Birmingham City Schools and/or the University of Alabama at Birmingham. METHODS: We took a concurrent mixed methods approach to conduct an environmental scan of health science pathway programs in the Birmingham, AL area. Four focus groups were conducted between November 2022 and January 2023, and a 225-item online survey was administered between November 4, 2022, and February 4, 2023. Both tools collected data from high school, undergraduate, and graduate students to examine key components of existing health care pathways programs for URMs and identify barriers and facilitators to successful implementation of such programs. RESULTS: Twenty-two students participated in the focus groups, and 168 individuals responded to the survey. Both focus group participants and interview respondents were primarily URMs (eg, 68.2% and 65.7% identified as Black or African American, respectively). Survey responses and focus group discussions showed that, overall, undergraduate and graduate students programs develop more robust identities as future health care professionals through friendships and institutional supports, expand their networks more broadly through mentorship, and feel more supported by family members in their academic endeavors than high school students. CONCLUSIONS: Health science pathway programs for URMs should facilitate and bolster social supports for students, especially those in high school, to enhance persistence through education and into the workforce.

Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model.

OBJECTIVES: To compare patient outcomes, resource use and costs to the NHS and NHS Blood Transfusion Authority (BTA) associated with cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion. DATA SOURCES: Electronic databases covering the period 1996-2004 for systematic reviews and 1994-2004 for economic evidence. REVIEW METHODS: Existing systematic reviews were updated with data from selected randomised controlled trials (RCTs) that involved adults scheduled for elective non-urgent surgery. Any resource use or cost data were extracted for potential use in populating an economic model. Relative risks or weighted mean difference of each outcome for each intervention were assessed, taking into account the number of RCTs included in each outcome and intervention and the presence of any heterogeneity. This allowed indirect comparison of the relative effectiveness of each intervention when the intervention is compared with allogeneic blood transfusion. A decision analytic model synthesised clinical and economic data from several sources, to estimate the relative cost-effectiveness of cell salvage for people undergoing elective surgery with moderate to major expected blood loss. The perspective of the NHS and patients and a time horizon of 1 month were used. The economic model was developed from reviews of effectiveness and cost-effectiveness and clinical experts. Secondary analysis explored the robustness of the results to changes in the timing and costs of cell salvage equipment, surgical procedure, use of transfusion protocols and time horizon of analysis. RESULTS: Overall, 668 studies were identified electronically for the update of the two systematic reviews. This included five RCTs, of which two were cell salvage and three preoperative autologous donation (PAD). Five published systematic reviews were identified for antifibrinolytics, fibrin sealants and restrictive transfusion triggers, PAD plus erythropoietin, erythropoietin alone and acute normovolaemic haemodilution (ANH). Twelve published studies reported full economic evaluations. All but two of the transfusion strategies significantly reduced exposure to allogeneic blood. The relative risk of exposure to allogeneic blood was 0.59 for the pooled trials of cell salvage (95% confidence interval: 0.48 to 0.73). This varied by the type and timing of cell salvage and type of surgical procedure. For cell salvage, the relative risk of allogeneic blood transfusion was higher in cardiac surgery than in orthopaedic surgery. Cell salvage had lower costs and slightly higher quality-adjusted life years compared with all of the alternative transfusion strategies except ANH. The likelihood that cell salvage is cost-effective compared with strategies other than ANH is over 50%. Most of the secondary analyses indicated similar results to the primary analysis. However, the primary and secondary analyses indicated that ANH may be more cost-effective than cell salvage. CONCLUSIONS: The available evidence indicates that cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage. The results of this analysis are subject to the low quality and reliability of the data used and the use of indirect comparisons. This may affect the reliability and robustness of the clinical and economic results. There is a need for further research that includes adequately powered high-quality RCTs to compare directly various blood transfusion strategies. These should include measures of health status, health-related quality of life and patient preferences for alternative transfusion strategies. Observational and tracking studies are needed to estimate reliably the incidence of adverse events and infections transmitted during blood transfusion and to identify the lifetime consequences of the serious hazards of transfusion on mortality, health status and health-related quality of life.

Economic evaluation of a randomized clinical trial of haemodilution with cell salvage in aortic surgery.

BACKGROUND: This study evaluated the costs of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage (ICS) versus homologous blood transfusion in aortic surgery in a prospective multicentre randomized trial. METHODS: One hundred and forty-five patients were randomized either to standard transfusion practice (homologous) or to a combination of ANH and ICS (autologous). Costs for each inpatient admission were identified. Cell salvage costs were assigned on the assumption that 50 operations were done each year employing a trained cell salvage operator. The results were analysed statistically using bias-corrected bootstrap analysis. RESULTS: Patients who had transfusion of homologous blood received some 251 units and those having a homologous transfusion received 103 units (P = 0.008). There was no difference in morbidity, mortality and duration of hospital stay. Transfusion-related mean costs were similar at 340 UK pounds for patients having a homologous transfusion and 357 UK pounds for those receiving autologous blood (mean difference 17 UK pounds (95 per cent confidence interval [c.i.]--184 UK pounds to 174 UK pounds); P not significant). There was also no significant difference in mean overall costs: 5859 UK pounds for homologous and 5384 UK pounds for autologous transfusion (mean difference--475 UK pounds (95 per cent c.i.--2231 UK pounds to 1342 UK pounds)). Sensitivity analysis showed that costs remained similar for 20 and 150 operations per annum. Exclusion of a dedicated cell salvage operator reduced autologous transfusion costs but did not have a significant impact on overall cost. CONCLUSION: Autologous transfusion is cost neutral in aortic surgery even when surgical activity is low.

Evaluating the cost and efficacy of leg ulcer care provided in two large UK health authorities.

OBJECTIVE: This prospective study investigated the cost and efficacy of leg ulcer care over a three-month period during 1993, 1994 and 1999. It compared two health authorities (Stockport and Trafford) whose populations totalled 540,000. METHOD: All patients with active leg ulcers were invited to community leg ulcer clinics offering research-based innovations in care. Patients without significant arterial disease (ankle brachial pressure index less than 0.8) were treated with multilayer compression bandaging. RESULTS: The 42% healing rate reported in the original Stockport study was maintained at 40% in 1999, although the 65% healing rate achieved by the leg ulcer clinics in 1993 was not replicated, with rates falling to 46%. Following the opening of community leg ulcer clinics in Trafford, healing rates rose from 20% to 42%. The annual expenditure on leg ulcer care in Stockport increased from 65,545.56 Pounds to 83,344.30 Pounds, while in Trafford the cost of care dropped from 151,375.35 Pounds to 53,176.76 Pounds between 1994 and 1999. CONCLUSION: This study suggests that reductions in costs and improvements in healing rates can be sustained in a mature community leg ulcer clinic programme staffed by specialist leg ulcer nurses.

Community leg ulcer clinics: a comparative study in two health authorities.

OBJECTIVE: To compare the outcome and cost of care for leg ulcers in community leg ulcer clinics in Stockport District Health authority with Trafford District Health Authority as a control. DESIGN: Detailed cost and efficacy studies conducted prospectively over a three month period in both districts both before and one year after the introduction of five leg ulcer clinics in Stockport. SETTING: Two large district health authorities of broad socioeconomic mix and total population of 540,000. PATIENTS: All patients receiving treatment for an active leg ulcer, irrespective of the profession or location of their carer. MAIN OUTCOME MEASURES: The proportion of ulcerated limbs completely healed within three months and total cost of leg ulcer care. RESULTS: The introduction of community clinics in Stockport improved healing of leg ulcers from 66/252 (26%) in 1993 to 99/233 (42%) in 1994 (P < 0.001) compared with in Trafford, where 47/203 (23%) healed in 1993 and only 43/213 (20%) in 1994. This improved result in Stockport was achieved while the annual expenditure on care of leg ulcers was reduced from 409,991 pounds to only 253,371 pounds. In the same year the cost of leg ulcer care in Trafford increased from 556,039 pounds to 673,318 pounds. CONCLUSION: In the first year after the introduction of community clinics, before most patients in Stockport had access to these clinics, healing of leg ulcers was already improved whereas costs were reduced.

Screening for abdominal aortic aneurysm: a computer assisted cost-utility analysis.

OBJECTIVES: To evaluate the effects of introducing routine ultrasonic screening for the identification and elective surgical treatment of abdominal aortic aneurysms (AAA) at high risk of rupture in the U.K. population of men aged 65-74 years. DESIGN: A computer assisted simulation of an AAA screening programme. The simulation incorporated assumptions gleaned from the literature about the epidemiology of AAA and the costs of screening. In addition, up-to-date costings based on recent Manchester (U.K.) vascular surgery experience are used. SETTING: A dialogue between National Health Service commissioners and providers to explore the feasibility and desirability of introducing AAA screening. CHIEF OUTCOME MEASURE: Cost per quality adjusted life year (QALY) gained. MAIN RESULTS: The absolute cost (circa 1992/3) per QALY gained from screening for and treating aneurysms of > or = 6 cm in diameter of pounds 1500 (benefit not discounted). Offsetting current treatment costs of ruptured aneurysms gives a net additional cost per QALY of pounds 1300. Screening and treating aneurysms of > or = 5 cm leads to a cost per QALY gained exceeding pounds 20000. The findings are robust under sensitivity analysis. CONCLUSIONS: Routine screening for AAAs of size > or = 6 cm compares favourably in terms of cost per QALY gained with services such as breast and cervical cancer screening.

Leg ulcer care: an audit of cost-effectiveness.

Our objective was to establish an audit mechanism to determine the cost and effectiveness of leg ulcer care across two Health Authorities. Following identification of all patients with active ulcers over a two-month period, leg ulcer treatment, costs and outcome were prospectively audited over three months. We found that leg ulcer care is currently expensive and appears to be largely ineffective, especially when compared to the community clinic approach.

Community leg ulcer clinics: cost-effectiveness.

This study investigates the cost-effectiveness and efficacy of a new service provided by community leg ulcer clinics, and compares it with treatment in existing hospital-based venous ulcer care clinics. Data were provided prospectively from district nurses and retrospectively from patients. Success in treatment was assessed as a percentage of ulcers completely healed after 12 weeks of treatment, analysed by the up-table method. Treatment success of 22% at 12 weeks using existing methods compared with 80% in community clinics. Costs were estimated to be 433,600 pounds and 169,000 pounds respectively. These findings indicate that community leg ulcer clinics were more effective and less expensive than the previous system of care.

A questionnaire to assess risk factors, quality of life, and use of health resources in patients with venous disease.

OBJECTIVE: To test the accuracy and usefulness of a questionnaire to assess risk factors and symptoms of venous disease, quality of life, and dependence on health and social services. DESIGN: Case-control study. SETTING: Multicentre study in three general practices. SUBJECTS: Patients drawn from a larger investigation of prevalence of venous disease. RESULTS: Patients who had venous disease were taller and heavier and had spent more time standing at work than those who did not. It was strongly associated with both number of pregnancies and number of children. There were weak but not significant associations with the wearing of a corset, constipation, and a family history of venous problems. CONCLUSIONS: The questionnaire was able to pick out recognised risk factors, and is suitable for use in studies of patients with venous disorders. It may also provide information about factors that have not yet been accepted. The case-control study is an appropriate way of assessing not only risk factors, but also signs and symptoms, quality of life, and use of health resources in patients with venous disease.

Polytetrafluoroethylene (PTFE) grafts for haemodialysis in chronic renal failure: assessment of durability and function at three years.

The utilization of 162 PTFE grafts for angio access in 131 patients over a three year period is reported. One hundred and three new PTFE arterio-venous fistulae were constructed in addition to 59 patch and tube incorporations into pre-existing graft fistulae. At three years, the cumulative patency of newly constructed grafts was 85%. Seventy four per cent of the grafts have had no thrombosis and are functioning up to 38 months following insertion. An aggressive approach was adopted towards the 15% of grafts that had at least one episode of thrombosis prior to flow being successfully restored. Graft occlusion which occurred up to 18 months following insertion, represented 11% of the group in this series. PTFE has provided an important advance in angio access for chronic renal failure with high patency and excellent durability after three years.