Waiting for cardiac surgery: results of a risk-stratified queuing process.

BACKGROUND: The Queen Elizabeth II Health Sciences Centre uses a weekly peer-review conference of cardiovascular experts to prioritize each surgical case to 1 of 4 queues with the use of standardized criteria of coronary anatomy, stress test result, and symptoms. We examined the hazard of waiting as well as the impact of waiting on surgical outcomes. METHODS AND RESULTS: Analysis was performed for 2102 consecutive patients queued for CABG, aortic valve replacement, or CABG+aortic valve replacement between January 1, 1998, and December 31, 1999. Among 1854 patients undergoing surgery, median waiting times on the respective queues were as follows: in-house urgent group, 8 days; semiurgent A group, 37 days; semiurgent B group, 64 days; and elective group, 113 days. There were 13 deaths (12 cardiac) that occurred during the waiting period (0.7% of the patients). Of the 8.7% patients upgraded to a more urgent queue, 86.1% required hospitalization before surgery. Although female sex was not associated with prolonged waiting time, it was predictive of urgent status (P=0.001). The incidence of postoperative complications was 25.0%, and operative mortality was 2.86%. Both were more frequent among patients undergoing surgery early (P=0.01); however, this difference was attributable to the in-house urgent queue. The median length of stay was 7 days for all patients and was not affected by waiting time. CONCLUSIONS: Death and upgrades while the patients were waiting tended to occur early in the queuing process, and prolonged waiting was not associated with worse surgical outcomes. The cost of reducing waiting times could in part be offset by prevention of hospital admissions among upgraded patients.

Financial viability, medical technology, and hospital closures.

Informed investments in medical technology and information systems are associated with the financial viability of community hospitals. Financially distressed facilities are 3 to 4 years behind proactive hospitals in supporting high-speed data, voice, and image transmissions to physicians in various locations. Impact of the Balanced Budget Act of 1997, fraud and abuse activities, Y2K issues, and lack of information systems support for physicians will result in 800 hospital closures and mergers of distressed hospitals over the next 60 months. These findings are based on the application of an eight-step framework for classifying information systems in health care entities. This framework is validated by survey instruments, site visits, interviews with senior management in 44 health care entities containing 576 hospitals, and judgments on the financial status of the health care entities.

Adolescent femoral shaft fractures: rigid versus flexible nails.

Twenty-one skeletally immature patients between 11 and 16 years of age were treated operatively for a unilateral femoral shaft fracture. Eleven patients underwent fixation with flexible nails and 10 with rigid nails. The patients were studied retrospectively to determine the similarity of the groups. Each method of fixation was then compared to determine the technical ease and final outcome. Both methods gave excellent final radiographic alignment with minimal complications. Flexible nailing required much less operative time and less fluoroscopy time. Estimated cost of using Ender nails is much less than using Russell-Taylor interlocking nails.

Butyltin and copper monitoring in a Northern Chesapeake Bay marina and river system in 1989: An assessment of tributyltin legislation.

This study was designed to: (1) evaluate dibutyltin (DBT) and tributyltin (TBT) bi-weekly in the water column for four months during the peak boating season (June-September, 1989) at seven stations in the Back Creek and Severn River area of Maryland waters of Chesapeake Bay; (2) compare butyltin values from the 1989 study with values obtained from a similar butyltin monitoring study conducted in 1988 (after Maryland TBT legislation) and 1986 (before Maryland TBT legislation); (3) determine the extent of TBT paint use in the Back Creek area by surveying boat owners; (4) determine dissolved copper concentrations from three of the seven stations bi-weekly during the four-month study; and (5) compare dissolved copper concentrations at these stations with previous copper data collected in 1988.Mean four-month DBT concentrations ranged from 10 to 73 ng/L at the seven stations. Highest DBT concentrations occurred at Station 1 in a marina; lowest concentrations occurred at Station 7 in the Severn River. Mean four-month TBT concentrations ranged from 177 ng/L at Station 1 (marina) to 21 ng/L at Station 7 (Severn River). Maximum TBT concentrations of 361 and 570 ng/L occurred at marina SDtations 1 and 3, respectively. Temporal trends in both DBT and TBT (station mean concentrations by date) showed that peak concentrations occurred during the early part of the boating season followed by reductions in late summer and early fall. Spike concentrations of both DBT (117 and 62 ng/L) and TBT (308 and 366 ng/L) were reported on two sampling dates near a boat maintenance facility in Back Creek.There was a significant reduction in DBT concentrations from 1986 to 1989 when date was treated as a fixed effect. However, TBT concentrations were not significantly reduced between 1986 and 1989 when mean concentrations of TBT were averaged across stations and dates for each year. A significant reduction was reported at Station 1 (marina station) when each station was examined for differences between years. TBT was also reported to significantly decrease (p=0.0442) at Station 7 between 1988 and 1989. A boat owner survey in the study area showed that 6% of the recreational boats that were surveyed were painted with TBT paint in 1989. This was a significant decrease in TBT paint use from the previous year when 31% of recreational boat owners surveyed used TBT paints.An evaluation of dissolved copper concentrations at three stations in the study area in 1989 showed that mean concentrations from bi-weekly sampling for four months was 10 µg/L at Station 1, 7.8 µg/L at Station 4 and 2.7 µg/L at Station 7. Copper concentrations decreased with distance away from the Back Creek marinas. Copper concentrations at all three stations were significantly lower in 1989 than in 1988.

A conceptual explanation of risk-reduction behavior and intervention development.

This study used a new conceptual model of health behavior to examine a specific risk-reduction response. Known to be at risk for fetal abnormalities because of maternal age, 203 women were examined for their acceptance or rejection of an amniocentesis test on the basis of individual characteristics and external significant factors. The multivariate approach to analysis offered a fuller explanation for nonuse of prenatal diagnosis than was previously available. In addition to specific client factors, environmental factors such as financial support for the procedure, multiple information sources, social support, and aspects of the client-provider interaction were determined to be important in explaining client acceptance or rejection of the test. More importantly, the study demonstrated the advantages of using a conceptual model to direct the development of interventions.

PIP: A new conceptual model of health behavior was used to examine a specific risk-reduction response. The focus of the model is on the process by which the client's individual characteristics combine with physiological, psychological, sociodemographic, environmental, and provider intervention factors to produce a selected health behavior. Known to be at risk for fetal abnormalities because of maternal age, 203 women were examined for their acceptance or rejection of an amniocentesis test on the basis of individual characteristics and external significant factors. The Prenatal Diagnosis Survey's variables and the elements and factors that comprise the structure of the Interaction Model of Client Behavior (IMCHB) were compared. Relative to the discrete variables, 70.9% of the women were covered for the amniocentesis by insurance; 45% of the women were Catholic; 57% lived outside the service county area; 5% of the clients were black; 96% were married; and 86% had discussed amniocentesis with a physician. The dependent measure included 57.6% of the clients who did not elect genetic counseling or amneocentis, 4.9% who chose counseling only, and 37.4% who chose amniocentesis postcounseling. 12 of the 30 variables examined were significantly associated with having or not having amniocentesis. Age, in correlation with absolute risk, was unexpectedly not highly associated with amniocentesis requests. 6 variables -- insurance coverage, experience with birth defects, age, religious affiliation (Catholic), education, and the amount of power desired by the mother deciding on abortion -- emerged as casually independent of any antecedents. The variables insurance coverage and experience with birth defects had a strong direct impact on the client's decision to request amniocentesis. Physician support has a significant impact on peer support for the procedure and on the number of people with whom the client discussed amniocentesis. Both social support for and against amniocentesis exerted powerful direct effects on the client's final decision about use of prenatal diagnosis. The final variable to directly influence the decision on amniocentesis is the client's attitude toward the legality of abortion (legal). In sum, the relationships predicted in abstraction by the IMCHB were demonstrated to be accurate when applied to clients' decisions to request amniocentesis. 22 of the 35 hypothesized causal paths were statistically significant; 5 paths were marginally significant.

Overcoming barriers to the employment and utilization of the nurse practitioner.

A national longitudinal cohort study of nurse practitioners and their employers conducted during 1973--1976 provided data on barriers to the development of the nurse practitioner role in primary care. Nearly 90 per cent of the 500 primary care nurse practitioners responding and 75 per cent of the 407 employers responding reported encountering one or more barriers to the role development of the nurse practitioner in their practice setting. Nurse practitioners identified an average of 2.2 barriers and employers identified an average of 1.6 barriers each. Specific barriers identified by 20 per cent or more of the nurse practitioners and employers were legal restrictions, limitations of space and facilities, and resistance from other providers. The data and other evidence suggest that these barriers are not insurmountable and that progress is being made in overcoming these obstacles.

The rural nurse practitioner: a challenge and a response.

From a cohort of 525 employed nurse practitioners (NPs) who graduated between May 1975 and June 1976, 85 (16 per cent) reported practicing in rural areas. While 91 per cent of the rural NPs chose the short-term certificate programs rather than the master's degree for their NP preparation, 47 per cent had already earned a baccalaureate or master's degree prior to NP training. Family NPs comprised the most frequent specialty area chosen, followed by pediatric and adult specialties. Of the 85, 99 per cent were actually providing a broad array of primary care services to clients over a wide age range. Physicians were periodically available on site in about 80 per cent of the practices, by telephone in 97 per cent of the practices, and in 60 per cent of the practices provided additional consulation by record review. Major motivations of the NPs for entering rural practice were to participate in a creative approach to health care delivery (50 per cent of the practice setting were less than five years old), and for the opportunity for role autonomy. Over 95 per cent of these NPs and employers were satisfied with the NP role.