A Dedicated Orthopaedic Trauma Room Improves Efficiency While Remaining Financially Net Positive.

OBJECTIVES: To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances. DESIGN: Retrospective cost-analysis. SETTING: Single midsized academic-affiliated community hospital in Toronto, Canada. PARTICIPANTS: All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included. INTERVENTION: Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed. MAIN OUTCOME MEASUREMENTS: The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries. RESULTS: One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476. CONCLUSIONS: Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Anesthesia Block Room Is Financially Net Positive for a Hospital Performing Arthroplasty.

INTRODUCTION: Regional anesthesia is increasingly used in total joint arthroplasty (TJA). It has shown efficiency benefits as it allows parallel processing of patients in a dedicated block room (BR). However, granular quantification of these benefits to hospital operations is lacking. The goal of this study was to determine the financial effect of establishing a BR using comprehensive operational modeling. METHODS: A discrete-event simulation model of daily operating room (OR) patient flow for TJA procedures at a mid-sized hospital was developed. Two scenarios were tested: (1) without and (2) with a BR. Scenarios were compared according to staffing requirements, hours/day, and labor costs. The number of ORs and cases varied from 2 to 6 ORs performing 3 to 5 cases. These results were used as the inputs of a discounted cash flow (CF) model. Discounted CF model outputs were CF, net present value, internal rate of return, and return on investment. RESULTS: Mean time savings of incorporating a BR were 68 min/d (range: 30 to 80 min/d), reducing the OR closing time by 1 hour. Incremental labor costs/day from nurse overtime pay ranged from $2,025 to $10,125 with no BR and $1,595 to $9,045 with a BR, which resulted in an increase in profit/day from $360 to $1,605. The CF/annum was $54,363, the net present value was $213,082, the internal rate of return was 12%, and the return on investment was 43.61%. DISCUSSION: This study demonstrates that under all scenarios, a BR is more profitable than no BR to a hospital performing TJA via a bundled care or private payer remuneration model. A BR was shown to be financially net positive even when considering the necessary financial investment to establish it. In addition, this study demonstrates the potential of combining discrete-event simulation with financial analyses to assess various operational models of care to improve hospital efficiency, such as dedicated trauma rooms and swing rooms. LEVEL OF EVIDENCE: Level III.

Collaborative community mental health and aged care services with peer support to prevent late-life depression: study protocol for a non-randomised controlled trial.

BACKGROUND: Late-life depression is common, modifiable, yet under-treated. Service silos and human resources shortage contribute to insufficient prevention and intervention. We describe an implementation research protocol of collaborative stepped care and peer support model that integrates community mental health and aged care services to address service fragmentation, using productive ageing and recovery principles to involve older people as peer supporters to address human resource issue. METHODS/DESIGN: This is a non-randomised controlled trial examining the effectiveness and cost-effectiveness of the "Jockey Club Holistic Support Project for Elderly Mental Wellness" (JC JoyAge) model versus care as usual (CAU) in community aged care and community mental health service units in 12 months. Older people aged 60 years and over with mild to moderate depressive symptoms or risk factors for developing depression will be included. JoyAge service users will receive group-based activities and psychoeducation, low-intensity psychotherapy, or high-intensity psychotherapy according to the stepped care protocol in addition to usual community mental health or aged care, with support from an older peer supporter. The primary clinical outcome, depressive symptoms, and secondary outcomes, self-harm risk, anxiety symptoms, and loneliness, will be measured with the Patient Health Questionnaire-9 (PHQ-9), Self-Harm Inventory, Generalized Anxiety Disorder 7-item scale (GAD-7), and UCLA Loneliness 3-item scale (UCLA-3) respectively. Cost-effectiveness analysis will assess health-related quality of life using the EQ-5D-5L and service utilisation using the Client Service Receipt Inventory (CSRI). We use multilevel linear mixed models to compare outcomes change between groups and calculate the incremental cost-effectiveness ratio in terms of quality-adjusted life years. DISCUSSION: This study will provide evidence about outcomes for older persons with mental health needs receiving collaborative stepped care service without silos and with trained young-old volunteers to support engagement, treatment, and transitions. Cost-effectiveness findings from this study will inform resource allocation in this under-treated population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593889. Registered on 20 July 2018.

Health and social care service utilisation and associated expenditure among community-dwelling older adults with depressive symptoms.

AIMS: Late-life depression has substantial impacts on individuals, families and society. Knowledge gaps remain in estimating the economic impacts associated with late-life depression by symptom severity, which has implications for resource prioritisation and research design (such as in modelling). This study examined the incremental health and social care expenditure of depressive symptoms by severity. METHODS: We analysed data collected from 2707 older adults aged 60 years and over in Hong Kong. The Patient Health Questionnaire-9 (PHQ-9) and the Client Service Receipt Inventory were used, respectively, to measure depressive symptoms and service utilisation as a basis for calculating care expenditure. Two-part models were used to estimate the incremental expenditure associated with symptom severity over 1 year. RESULTS: The average PHQ-9 score was 6.3 (standard deviation, s.d. = 4.0). The percentages of respondents with mild, moderate and moderately severe symptoms and non-depressed were 51.8%, 13.5%, 3.7% and 31.0%, respectively. Overall, the moderately severe group generated the largest average incremental expenditure (US$5886; 95% CI 1126-10 647 or a 272% increase), followed by the mild group (US$3849; 95% CI 2520-5177 or a 176% increase) and the moderate group (US$1843; 95% CI 854-2831, or 85% increase). Non-psychiatric healthcare was the main cost component in a mild symptom group, after controlling for other chronic conditions and covariates. The average incremental association between PHQ-9 score and overall care expenditure peaked at PHQ-9 score of 4 (US$691; 95% CI 444-939), then gradually fell to negative between scores of 12 (US$ - 35; 95% CI - 530 to 460) and 19 (US$ -171; 95% CI - 417 to 76) and soared to positive and rebounded at the score of 23 (US$601; 95% CI -1652 to 2854). CONCLUSIONS: The association between depressive symptoms and care expenditure is stronger among older adults with mild and moderately severe symptoms. Older adults with the same symptom severity have different care utilisation and expenditure patterns. Non-psychiatric healthcare is the major cost element. These findings inform ways to optimise policy efforts to improve the financial sustainability of health and long-term care systems, including the involvement of primary care physicians and other geriatric healthcare providers in preventing and treating depression among older adults and related budgeting and accounting issues across services.

Robotic minor hepatectomy: optimizing outcomes and cost of care.

BACKGROUND: The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. METHODS: We queried the medical record and cost data for patients who underwent open or robotic minor (1-2 segment) liver resection from 1/2016-8/2019. Financial data were normalized to Medicare reimbursements. RESULTS: There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p < 0.001) were significantly lower for patients who underwent robotic resection. These factors contributed to minor robotic liver resections costing $534 less than open resections ($3597 ± 1823 vs $4131 ± 1532, p = 0.03). CONCLUSION: Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

Academic Productivity in Hepatopancreatobiliary Surgeons: Identifying Benchmarks Associated With Rank in North America.

BACKGROUND: Academic achievement is an integral part of the promotion process; however, there are no standardized metrics for faculty or leadership to reference in assessing this potential for promotion. The aim of this study was to identify metrics that correlate with academic rank in hepatopancreaticobiliary (HPB) surgeons. MATERIALS AND METHODS: Faculty was identified from 17 fellowship council accredited HPB surgery fellowships in the United States and Canada. The number of publications, citations, h-index values, and National Institutes of Health (NIH) funding for each faculty member was captured. RESULTS: Of 111 surgeons identified, there were 31 (27%) assistant, 39 (35%) associate, and 41 (36%) full professors. On univariate analysis, years in practice, h-index, and a history of NIH funding were significantly associated with a surgeon's academic rank (P < .05). Years in practice and h-index remained significant on multivariate analysis (P < .001). DISCUSSION: Academic productivity metrics including h-index and NIH funding are associated with promotion to the next academic rank.

Minimally invasive distal pancreatectomy and the cost of conversion.

BACKGROUND: Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS: A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS: There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS: Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.

Growing Old as a Member of an Ethnic Minority in Hong Kong: Implications for an Inclusive Long-Term Care Policy Framework.

Hong Kong is experiencing significant demographic changes as a result of rapid population aging and immigration. Anecdotal evidence suggests that ethnic minorities, in particular aged members of South Asian ethnic minorities, face significant and diverse obstacles in accessing services important to their general welfare. This study is the first systematic attempt to explore the long-term care needs of Nepalese older adults in Hong Kong and the barriers they face in accessing long-term care services. Data were obtained through semi-structured interviews with 30 Nepalese older adults. We found that Nepalese older adults have similar physical and psychosocial needs as those of their local Chinese counterparts. However, participants face a range of structural, knowledge, and attitudinal barriers that together deter them from accessing long-term care services, despite their right to do so. Policy recommendations to mitigate these barriers are given, with reference to the World Health Organization's Age-Friendly Cities Framework.

Academic productivity in surgical oncology: Where is the bar set for those training the next generation?

BACKGROUND AND OBJECTIVES: Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation. METHODS: Faculty were identified from accredited surgical oncology fellowships in the United States. Scopus was used to obtain the number of publications/citations and h-index values. The National Institutes of Health (NIH) RePORT website was used to identify funding history. RESULTS: Of the 319 surgeons identified, complete rank information was obtained for 308. The majority of faculty were men (70%) and only 11% of full professors were women. The median h-index values were 7, 17, and 39 for assistant, associate, and full professors, respectively. While 50% of full professors had a history of NIH funding, only 26% had RO1s and 20% had current NIH funding. Using multivariate analysis, years in practice, h-index, and a history of NIH funding were associated with academic rank (P < .05). CONCLUSION: Objective benchmarks, such as the median h-index and NIH funding, provide additional insights for both junior faculty and leadership into the productivity needed to attain promotion to the next academic rank for surgical oncologists.

Cohort Profile: FAMILY Cohort.

The FAMILY Cohort is a longitudinal study of health, happiness and family harmony (the '3Hs') at individual, household and neighbourhood levels in Hong Kong. Using a family living in the same household as the sampling unit, the study (n = 20 279 households and 46 001 participants) consists of a composite sample from several sources, including: a population-representative random core sample (n = 8115 households and 19 533 participants); the first-degree relatives of this sample (n = 4658 households and 11 063 participants); and oversampling in three new towns (n = 2891 households and 7645 participants) and in three population subgroups with anticipated changes in family dynamics (n = 909 households and 2160 participants). Two household visits and five telephone- or web-based follow-ups were conducted over 2009-14. Data collected include socio-demographics, anthropometrics, lifestyle and behavioural factors, measures of social capital, and standardized instruments assessing the 3Hs. We also intend to collect biomaterials in future. The analytical plan includes multilevel inter-relations of the 3Hs for individuals, households, extended families and neighbourhoods. With Hong Kong's recent history of socioeconomic development, the FAMILY Cohort is therefore relevant to global urban populations currently experiencing similarly rapid economic growth. The FAMILY Cohort is currently set up as a supported access resource.

Culturally Relevant Protective and Risk Factors of Youth Risk Behaviors Among Pakistani and Indian Students in Hong Kong: A Focus Group Study.

PURPOSE: The risk behaviors of Hong Kong ethnic minority students are understudied. This exploratory qualitative study aimed to explore culturally nuanced factors for the development and prevention of risk behaviors among Pakistani and Indian students in Hong Kong. METHOD: Twenty-three students participated in four focus groups. All interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: The participants reported bullying, delinquency, gambling, alcohol, cigarette, and drug uses as risk behaviors. Four themes emerged in the development and prevention of risk behaviors: (a) Parental and peer influence, (b) An unsafe community environment were perceived by the participants as essential factors for the development of risk behaviors, (c) Parental monitoring, and (d) Strong religious beliefs were believed as protective factors for the prevention of risk behaviors. CONCLUSION: Further research and practice may investigate and focus on the factors embedded in the Hong Kong ethnic minorities' sociocultural contexts to prevent risk behaviors.

An ecological analysis of secondary school students' drug use in Hong Kong: A case-control study.

BACKGROUND: Youth drug use is a significant at-risk youth behaviour and remains as one of the top priorities for mental health services, researchers and policy planners. The ecological characteristics of secondary school students' behaviour in Hong Kong are understudied. AIM: To examine individual, familial, social and environmental correlates of drug use among secondary students in Hong Kong. METHOD: Data were extracted from a school survey with 3078 students. Among the 3078 students, 86 students reported to have used drugs in the past 6 months. A total of 86 age- and gender-matched controls with no drug-use behaviour in the past 6 months were randomly selected from the remaining students. Multiple logistic analysis was used to examine differential correlates between those who used and did not use substance in the past 6 months. RESULT: Positive school experience and perspective to school and parental support are protective factors of drug use. Lower self-esteem, lower self-efficacy against using drugs and higher level of permissive attitude towards drugs were associated with drug use. Students who were low in self-esteem and rather impulsive tend to use drugs. CONCLUSION: To prevent students from drug use, efforts in individual, family, school and community-levels should be addressed.

Suicides by jumping from a height in Hong Kong: a review of coroner court files.

PURPOSE: Jumping from a height is the most common method for suicide in Hong Kong and other urban cities, but it remains understudied locally and internationally. We used Coroner records in exploring the ecological factors associated with these deaths and the personal characteristics of persons who jumped to their death (hereafter, "jumping suicides"). We compared suicides by jumping with all other suicides and examined the suicides that occurred at ten different jumping sites. METHODS: The Coroner's files of all suicides in Hong Kong from 2002 to 2007 included 6,125 documented deaths. RESULTS: 2,964 (48.4%) involved jumping during the study period. Eighty-three percent (83%) of suicide jumps occurred in residential buildings, and of these, 61% occurred from the decedent's own home. Jumping suicides differed from non-jumping suicides in terms of their socio-demographic characteristics (e.g., for male: 60.8 vs. 67.3% of jumping suicide and non-jumping suicides, p < 0.0001) and the presence of physical illness (44.4 vs. 42.7% for jumping and non-jumping suicides, p < 0.0001). While statistically significant, these differences are relatively modest. In contrast, 40.7 documented illnesses vs. 23.1% for jumping and non-jumping suicides (p < 0.0001). CONCLUSIONS: Means restriction is a key strategy for suicide prevention. Installation of physical barriers, one of the mean restriction strategies, at common places for suicide has strong evidence to avert suicides without substitution effects. There seems to be challenges to implement physical barriers to prevent residential jumping suicides. Simply applying physical barriers to preclude jumping in Hong Kong appears to be difficult given its ubiquitous "high-rise" residential dwellings. Hence, we also need to develop alternative strategies aimed at preventing people from becoming suicidal.

Effectiveness of a universal school-based programme for preventing depression in Chinese adolescents: a quasi-experimental pilot study.

BACKGROUND: Evidence of the effectiveness, rather than efficacy, of universal school-based programmes for preventing depression among adolescents is limited. This study examined the effectiveness of a universal depression prevention programme, "The Little Prince is Depressed" (LPD), which adopted the cognitive-behavioural model and aimed to reduce depressive symptoms and enhance protective factors of depression among secondary school students in Hong Kong. METHODS: A quasi-experimental design was adopted for this pilot study. Thirteen classes were assigned to the intervention or control conditions according to the deliberation of the programme administrator of the four participating schools. Implementation was carried out in two phases, with a professional-led first phase and teacher-led programme second phase. LPD consisted of a 12-week school-based face-to-face programme with psycho-educational lessons and homework assignments. RESULTS: Students completed the programme generally showed positive development in help-seeking attitudes and self-esteem. For students who had more depressive symptoms at pre-assessment, the programme was found to be significant in enhancing cognitive-restructuring skills and support-seeking behaviours. The programme was not, however, found to be statistically significant in reducing depressive symptoms of the participants over the study period. LIMITATIONS: A small sample size, a high attrition rate, and a short follow-up time frame. CONCLUSIONS: The LPD programme was successful in building resilience of the students in general and enhancing the cognitive-behavioural skills of students with depressive symptoms. While we did not find sufficient evidence for concluding that the LPD was effective in reducing depressive symptoms, we believe that these results highlight the challenges of implementing evidence-based practices generated from highly controlled environments in real-life settings.

Screening for depression with the Patient Health Questionnaire-2 (PHQ-2) among the general population in Hong Kong.

BACKGROUND: This study investigates the psychometric properties of the Patient Health Questionnaire-2 (PHQ-2) in the general population of Hong Kong. METHODS: Random sampling was used to recruit 6028 participants aged 15 years or over. Among them, 203 were surveyed twice within a two-week period. Participants completed the Chinese version of the PHQ-9 (including 2 items of the PHQ-2), the Chinese Health Questionnaire, the Happiness Scale, the SF-12, and questions about diagnosis and health service utilization. Internal consistency, test-retest reliability, construct and discriminant validity of the PHQ-2 were assessed. RESULTS: Cronbach's α was 0.76. The test-retest reliability over two weeks calculated by intraclass correlation was 0.70. Spearman correlation results showed that the PHQ-2 score was associated with the remaining seven items of the PHQ-9 (r = 0.53), the Chinese Health Questionnaire (r = 0.37), and the Happiness scale (r = -0.32). As expected, the strength of the correlation between the PHQ-2 and the SF-12 Physical Component Summary was lower (r = -0.29) than that with the SF-12 Mental Component Summary (r = -0.50). Participants with higher PHQ-2 scores more frequently reported having received a depression diagnosis made by a doctor, having chronic illness, using medicine, and utilizing health services. Using the cutoff point ≥ 3, 4.2% of participants screened positive for Major Depressive Disorder. LIMITATIONS: We did not use diagnostic interviews or other depression measures to test the PHQ-2's relative performance in screening for depression. CONCLUSIONS: This study provides evidence for the PHQ-2 as a reliable and valid screening tool for depressive symptoms among a randomly recruited community sample in Hong Kong.

Assessment of selection bias in the Canadian case-control study of residential magnetic field exposure and childhood leukemia.

The authors evaluated the role of selection bias in the 1999 Canadian case-control study of residential magnetic field exposure and childhood leukemia. They included cases, participating controls, and first-choice nonparticipating controls in their analyses. Exposure was assessed by wire coding, a classification system based on the distribution line characteristics near homes. Although an imperfect measure of magnetic field exposure, wire coding is the only method applicable to nonparticipating subjects. First-choice nonparticipant controls tended to be of lower socioeconomic status than their replacements (non-first-choice participant controls), and lower socioeconomic status was related to higher wire code categories. The odds ratios for developing childhood leukemia in the highest exposure category were 1.6 (95% confidence interval: 1.0, 2.6) when the actual participating controls were used and 1.3 (95% confidence interval: 0.8, 2.1) when the first-choice ideal controls were used, regardless of their participation. Overall, the authors conclude that, although there is some evidence for control selection or participation bias in the Canadian study, it is unlikely to explain entirely the observed association between magnetic field exposure and childhood leukemia. Inherent problems in exposure assessment for nonparticipating subjects, however, limit the interpretations of these results, and the role of selection bias cannot entirely be dismissed on the basis of these results alone.