The health and welfare effects of environmental governance: Evidence from China.

Environmental regulations aim to reduce pollution and improve air quality and the health of residents. However, there is a lack of research focusing on the health and welfare effects of low-carbon city pilot policies. In this context, this study takes China's low-carbon city pilot policy as an entry point, focuses on the health effects of public environmental governance, and systematically investigates the effects and mechanisms of low-carbon city development on the health of middle-aged and elderly people by applying the difference-in-differences method. The study finds that low-carbon city (LCC) policy significantly improves the physical and mental health of middle-aged and elderly people, and the main transmission mechanism is the reduction in air pollution and improvement in social capital. These results hold following a series of robustness tests. Furthermore, low-carbon city construction can reduce hospitalization and outpatient costs for people over 45 years old by up to 3 % and 15.5 %, respectively. The findings of this study provide useful policy insights for ensuring sustainable improvement in environmental quality and public health.

Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data.

STUDY OBJECTIVES: To characterize the incidence of pediatric narcolepsy diagnosis, subsequent care, and potential sociodemographic disparities in a large US claims database. METHODS: Merative MarketScan insurance claims (n=12,394,902) were used to identify youth (6-17 years) newly diagnosed with narcolepsy (ICD-10 codes). Narcolepsy diagnosis and care 1-year post-diagnosis included polysomnography (PSG) with Multiple Sleep Latency Test (MSLT), pharmacological care, and clinical visits. Potential disparities were examined by insurance coverage and child race and ethnicity (Medicaid-insured only). RESULTS: The incidence of narcolepsy diagnosis was 10:100,000, primarily type 2 (69.9%). Most diagnoses occurred in adolescents with no sex differences, but higher rates in Black versus White youth with Medicaid. Two-thirds had a prior sleep disorder diagnosis and 21-36% had other co-occurring diagnoses. Only half (46.6%) had a PSG with MSLT (± 1-year post-diagnosis). Specialty care (18.9% pulmonary, 26.9% neurology) and behavioral health visits were rare (34.4%), although half were prescribed stimulant medications (51.0%). Medicaid-insured were 86% less likely than commercially insured youth to have any clinical care and 33% less likely to have a PSG with MSLT. CONCLUSIONS: Narcolepsy diagnoses occurred in 0.01% of youth, primarily during adolescence, and at higher rates for Black versus White children with Medicaid. Only half had evidence of a diagnostically required PSG with MSLT, underscoring potential misdiagnosis. Many patients had co-occurring conditions, but specialty and behavioral health care were limited. Results suggest misdiagnosis, underdiagnosis, and limited narcolepsy treatment, as well as possible insurance-related disparities. Results highlight the need to identify determinants of evidence-based pediatric narcolepsy diagnosis and management.

Drug design education in China.

With the emergence of innovative technologies, including combinatorial chemistry, high-throughput screening, computer-aided drug design (CADD), artificial intelligence (AI) and big data, the importance of drug design in the field of drug discovery and development is increasing. Additionally, education in drug design plays an important role in the training of pharmaceutical talent. Starting with undergraduates, cultivating pharmaceutical design thinking, developing innovation and creativity, and establishing an interdisciplinary knowledge system will not only provide students with a solid knowledge basis but also promote the development of the pharmaceutical industry in China. This article presents the current status of pharmaceutical education and the distribution of drug design courses in China and summarizes the employment prospects of graduates, thus providing valuable references and evidence for global pharmaceutical design education.

A remanufacturing supply chain network with differentiated new and remanufactured products considering consumer preference, production capacity constraint and government regulation.

Remanufacturing is a sustainable product reutilization strategy to realize responsible consumption and production. However, remanufacturing practice can be subject to deficient consumer perception, production capacity constraint, uncertain demand and government intervention. This paper considers outsourced remanufacturing mode to establish and investigate a remanufacturing supply chain (RSC) network consisting of multiple manufacturers, retailers and remanufacturers. Optimality conditions with RSC network members are derived utilizing variation inequality. Numerical examples based on data accumulated from a remanufacturing enterprise and questionnaire survey on consumer perception for remanufactured products, are presented to put the proposed model into practice. Influences of product heterogeneity (new and remanufactured products), consumer preference, production capacity constraint, product price competitiveness, market demand fluctuation, and government financial measures on RSC network production and pricing strategies are investigated through numerical analyses. Analytical results indicate that pricing for the remanufactured product would be equivalent to that of the new product when consumers value the remanufactured product at a relatively high level, however an excessive penchant for the remanufactured product is less profitable especially from the perspective of the remanufacturer. In general, an upper-middle level of consumer preference for the remanufactured product is the most favourable scenario. When remanufacturing industry is just emerging, a high tax will be imposed on the manufacturer to accumulate remanufacturing subsidy for the government to achieve its balanced budget. As the remanufacturing industry develops and consumer environmental awareness enhances, it is especially essential for the government to establish a levy-subsidy mechanism to maintain sustainable progress of the industry. Combining main conclusions with the background of Chinese remanufacturing industry, managerial implications are provided from respective perspectives of enterprises' remanufacturing operation, government financial regulation, and consumer awareness enhancement. The analyses and results are especially relevant as a reference for remanufacturing decision-makings as well as government financial regulations, thus enhancing production sustainability as well as environmental benefits.

Assessment of a training project of English as a media of instruction(EMI) using Kirkpatrick model.

BACKGROUND: English as a Media of Instruction (EMI) teacher development project is based upon the framework for teacher Continuing Professional Development (CPD) and aims to effectively improve both the confidence and overall capacity of EMI lecturers. Kunming Medical University(KMU) conducted the EMI training project to improve teachers' competence for MBBS education. This study aimed to assess teachers' changes following the implementation of this training project, via the Kirkpatrick evaluation model. METHODS: A total of trainees (n = 84) were invited as the research objects. The effects of the EMI training project implemented in KMU were evaluated in terms of the reaction, learning, and behavior dimensions based on the Kirkpatrick model. The self-administered online anonymous questionnaires and observations of participants' EMI lectures were administered to all participants to collect the data. Furthermore, to understand participants' perceptions of the management and trainers of the training project, some open-ended questions were required to answer. RESULTS: Based on 1-3 level of the Kirkpatrick model, all participants were highly satisfied with the EMI training implementation on the reaction level, and expressed positive comments about the management of the training and trainers. On the learning level, participants' scores on awareness of EMI teaching techniques increased significantly(t = 7.122, P < 0.001)with the training process. Concerning the behavior level, the participant's confidence as an EMI instructor increased dramatically at end of the whole training(p < 0.001). Moreover, trainees had applied some EMI skills in class and would like to make some commitment to implement learner-centered learning, to do more practice on EMI techniques. CONCLUSION: The findings of this study confirm that EMI training has an effective impact on the competence and confidence of participants as EMI instructors at levels 1-3 of the Kirkpatrick evaluation model. This training may be a potentially beneficial effect on the teaching quality of MBBS education.

[Discussion on the scientific concepts of regional resources and environmental carrying capacity and its ecological basis.] / åŒºåŸŸèµ„æºçŽ¯å¢ƒæ‰¿è½½åŠ›ç§‘å­¦æ¦‚å¿µåŠå ¶ç”Ÿæ€å­¦åŸºç¡€çš„è®¨è®º.

The carrying capacity of resources and environment is an essential concept in ecology, the theoretical and practical research of which has become an important basis for measuring regional sustainable development. However, the scientific connection between the ecological foundation and the carrying capacity of resources and environment is still unclear. Moreover, it remains unknown which ecological theories played a supporting role in the development of the resources and environment carrying capacity, which makes the scientific concept of carrying capacity very vague. Based on the discussion of the scientific concepts and development of the carrying capacity of resources and environmen, we systematically discussed the basic concepts, such as the niche volume that organisms can occupy, the ecological threshold of ecosystems to withstand environmental stress, the potential resource capacity (supply capacity) of sustainable supply such as climate, water and nutrition, and the environmental capacity of buffering and purifying pollutants. Furthermore, from the biophysical point perspective of foundation pressure bearing capacity, spatial capacity carrying capacity and ecological threshold carrying capacity, the scientific concepts of Natural Resources Supply Carrying Capacity (NRSCC), Nature Environment Carrying Capacity (NECC), Carrying Capacity of Biological Population Development (CCBPD), Carrying Capacity of Social and Economic Development (CCSED) and Carrying Capacity of Environmental Stress in Ecosystems (CCESE) were defined. Finally, three basic issues of ecology were discussed in detail, including the theory of population growth and the ecological capacity of the ecosystem, the theory of ecosystem multi-functionality and resource and environmental effects, and the theory of alternative stable states, self-adaptability, and self-organization. Based on exploring the theory and method of regional resource environmental assessment, this study would provide theoretical basis for regional resource environment utilization, protection and social and economic sustainable development.

[Evaluation theory and method of regional resources and environmental carrying capacity.] / 区域资源环境承载力的评价理论及方法讨论.

Our understanding of resources and environmental carrying capacity is deepened with the comprehensive effects of human needs and external stress. When human survival and development mainly depend on the supply of local resources and environmental conditions, the resources and environmental carrying capacity is largely controled by the dominant limiting factors. With sustainable development and environmental protection, the resources and environmental carrying capacity has gradually changed from supply restriction to demand support. There is an expression of capacity, threshold, intensity, and ability to characterize the resources and environmental carrying capacity. The impact of climate change and human activities on the resource and environmental system is increasing, altering resources and environmental carrying capacity. At present, the interrelationship and internal mechanism among resource and environmental carrying capacity, ecosystem vulnerability, and climate change risk are still unclear, which restricts the further development of theory and method. We preliminarily summarized and discussed the basic theory and method system of the research on carrying capacity of regional resources and environment. Furthermore, we advocated to develop the cascade relations of "carrying capacity of biological population development-carrying capacity of environmental stress in ecosystems-natural resources supply carrying capacity-natural environment carrying capacity-carrying capacity of social and economic development". Moreover, the calculation method and conceptual model of multi-dimensional resource and environmental carrying capacity were put forward under each concept framework. This study provided new ideas for the research on the method of resources and environment carrying capacity.

Extended Warranty Strategy and Its Environment Impact of Remanufactured Supply Chain.

To reduce environmental pollution, the government has issued relevant laws and regulations, and more and more enterprises engage in remanufacturing and recycling used products. Trade old for new and trade old for remanufactured have become marketing means to promote product recycling. The extended warranty service is used to promote the recycling of waste products. To design an optimal extended warranty service strategy and analyze its environment impact in a remanufactured supply chain, game theory is used to model the competitive relationship between a manufacturer and an E-commerce platform. Considering whether the E-commerce platform provides extended warranty service, four models are constructed, and the extended warranty service strategy and its environment impact can be analyzed. The results show that, when the level of substitutability between remanufactured and new products meets a certain rage, new or remanufactured products with extended warranty service strategy can increase the demand for new or remanufactured products, respectively. In the four models, the changing trends of manufacturer's profit, E-commerce platform's profit and supply chain's profit, consumer surplus, environmental impact and social welfare are the same, but only the thresholds are different. From the perspectives of supply chain member, supply chain system, consumer, environment and society, the new and remanufactured products with extended warranty service strategy is the best choice.

Greater admissions, mortality and cost of heart failure in adults with congenital heart disease.

OBJECTIVE: Limited contemporary data exist regarding outcomes and resource use among adults with congenital heart disease and heart failure (ACHD-HF). This study compared outcomes, emergency department (ED) and hospital resource use, and advanced heart failure (HF) therapies in ACHD-HF versus non-ACHD with HF (HF-non-ACHD). METHODS: The Nationwide Emergency Department Sample and Nationwide Inpatient Sample were used to analyse outcomes and resource use among ACHD-HF ED visits and hospitalisations from 2006 to 2016. ACHD-HF was stratified by single-ventricle (SV) and two-ventricle (2V) disease. RESULTS: A total of 76 557 ACHD-HF visits (3.6% SV physiology) and 31 137 414 HF-non-ACHD visits were analysed. ACHD-HFs were younger (SV 33 years (IQR 25-44), 2V 62 years (IQR 45-76); HF-non-ACHD 74 years (IQR 63-83); p<0.001). ACHD-HFs had higher ED admissions (78% vs 70%, p<0.001), longer hospital length of stay (5 days (IQR 2-8) vs 4 days (IQR 2-7), p<0.001) and greater hospital costs ($49K (IQR 2K-121K) vs $32K (17K-66K), p<0.001). Mortality was significantly higher among ACHD-HFs with SV physiology (6.6%; OR 1.6, 95% CI 1.1 to 2.3) or 2V physiology (6.3%; OR 1.4, 95% CI 1.3 to 1.5) versus HF-non-ACHD (5.5%). ACHF-HF hospitalisations increased more (46% vs 6% HF-non-ACHD) over a 10-year period, but the proportion receiving ventricular assist device (VAD) (ACHD-HF -2% vs HF-non-ACHD 294%) or transplant (ACHD-HF -37% vs HF-non-ACHD 73%) decreased. CONCLUSION: ACHD-HFs have significant ED and hospital resource use that has increased over the past 10 years. However, advanced HF therapies (VAD and transplantation) are less commonly used compared with those without adult congenital heart disease.

The Chinese version of attitudes towards guidelines scale: validity and reliability assessment.

BACKGROUND: The use of guidelines has shown to improve clinical practice process and structure of health care, but health care providers don't always use and keep up-to-date with the new clinical practice guidelines. Nurses' attitudes towards guidelines have shown to be the most frequently identified factor affecting their actual use of clinical practice guidelines, but no instruments for measuring it are available in China. There are scales validated in the western countries, but there is no information about their validity in Chinese health care. The purpose of this study is to test the validity and reliability of Chinese Attitudes towards guidelines - scale for nurses. METHODS: The study was conducted from April to July 2017. The Attitudes towards guidelines scale was translated into Chinese with forward-backward translation method and a questionnaire survey was conducted. Eight hundred randomly selected nurses (final N = 768) from Geriatrics, Internal medical and Rehabilitation departments of 16 hospitals were drawn in Sichuan province, China. Construct validity was evaluated by exploratory and confirmatory factor analysis, and reliability was assessed by test-retest reliability (represented by intra class correlation) and internal consistency (expressed by Cronbach's coefficients). The test-retest reliability was examined with a sample of 32 clinical nurses who filled out the questionnaire 14 days after the first survey. RESULTS: Exploratory factor analysis supported a four-factor model for the Chinese version of the scale. Confirmatory factor analysis indicated that the hypothetical four-factor model fitted the data relatively well. The intra class correlation coefficient was 0.85 (95%CI, 0.68-0.93) and the Cronbach's alpha values for the four subscales ranged from 0.645 to 0.912. CONCLUSIONS: The results support the acceptable level of validity and reliability of the Chinese version of Attitudes towards guidelines scale, which can be used to assess nurses' attitudes towards guidelines in China. Future testing for the Chinese version of Attitudes towards guidelines scale needs to be carried out to see whether these results are generalizable to other professionals and occupational groups and to be used to revise attitudes towards specific guidelines in China.

Longitudinal Assessment of Outcome From Prenatal Diagnosis Through Fontan Operation for Over 500 Fetuses With Single Ventricle-Type Congenital Heart Disease: The Philadelphia Fetus-to-Fontan Cohort Study.

Background Prenatal diagnosis of single ventricle-type congenital heart disease is associated with improved clinical courses. Prenatal counseling allows for optimal delivery preparations and opportunity for prenatal intervention. Expectant parents frequently ask what the likelihood of survival through staged palliation is and the factors that influence outcome. Our goal was specifically to quantify peri- and postnatal outcomes in this population. Methods and Results We identified all patients with a prenatal diagnosis of single ventricle-type congenital heart disease presenting between July 2004 and December 2011 at our institution. Maternal data, fetal characteristics, and data from the postnatal clinical course were collected for each patient. Kaplan-Meier curves and multivariate analysis with logistic regression were used to evaluate variables associated with decreased transplant-free survival. Five hundred two patients were identified, consisting of 381 (76%) right ventricle- and 121 left ventricle-dominant lesions. After prenatal diagnosis, 42 patients did not follow up at our center; 79 (16%) chose termination of pregnancy, and 11 had intrauterine demise with 370 (74%) surviving to birth. Twenty-two (6%) underwent palliative care at birth. Among 348 surviving to birth with intention to treat, 234 (67%) survived to at least 6 months post-Fontan palliation. Presence of fetal hydrops, right ventricle dominance, presence of extracardiac anomalies, and low birthweight were significantly associated with decreased transplant-free survival. Conclusions In patients with a prenatal diagnosis of single ventricle-type congenital heart disease and intention to treat, 67% survive transplant-free to at least 6 months beyond Fontan operation. An additional 5% survive to 4 years of age without transplant or Fontan completion. Fetuses with right ventricle-dominant lesions, extracardiac anomalies, hydrops, or low birthweights have decreased transplant-free survival.

Engineering detoxified pneumococcal pneumolysin derivative ΔA146PLY for self-biomineralization of calcium phosphate: Assessment of their protective efficacy in murine infection models.

Vaccine design ushered in the era of nanotechnology, as the vaccine is being developed toward particulate formulation. We have previously shown that the attenuated pneumolysin mutant (ΔA146PLY) was a safe and effective pneumococcal vaccine candidate. Here, to further optimize the formulation, we fused calcium phosphate (CaP) binding domains with ΔA146PLY so that the biocompatible CaP can mineralize with the protein automatically, allowing simple production of nanoparticle antigen during preparation. We fabricated four different nanoparticles, and then we compared the characteristics of different CaP-ΔA146PLY nanoparticles and demonstrated the influence of CaP binding domains on the size, shape and surface calcium content of the nanoparticles. It was found that these self-biomineralized CaP-ΔA146PLY nanoparticles varied in their capacity to induce BMDCs and splenocytes production of cytokines. We further demonstrated that, compared to free proteins, nanoparticle antigens induced more efficient humoral and cellular immune responses which was strong enough to protect mice from both pneumonia and sepsis infection. Also, the integration of CaP to protein has no significant impairment on body weight of animals, and subcutaneous injection of ΔA146PLY-peptides@CaP nanoparticles did not lead to permanent formation of nodules in the skin relative to Alum adjuvant formulated antigens. Together, our data sufficiently suggest that soluble ΔA146PLY vaccine candidate could be processed into nanoparticles by self-biomineralization of CaP, the immunogenicity of which could be efficiently improved by the CaP binding domains and biomineralization.

Quantitative assessment of ratiometric bimolecular beacons as a tool for imaging single engineered RNA transcripts and measuring gene expression in living cells.

Recently, we developed an oligonucleotide-based probe, ratiometric bimolecular beacon (RBMB), which generates a detectable fluorescent signal in living cells that express the target RNA. Here, we show that RBMBs can also be used to image single RNA transcripts in living cells, when the target RNA is engineered to contain as few as four hybridization sites. Moreover, comparison with single-molecule fluorescence in situ hybridization confirmed that RBMBs could be used to accurately quantify the number of RNA transcripts within individual cells. Measurements of gene expression could be acquired within 30 min and using a wide range of RBMB concentrations. The ability to acquire accurate measurements of RNA copy number in both HT-1080 cells and CHO cells also suggests that RBMBs can be used to image and quantify single RNA transcripts in a wide range of cell lines. Overall, these findings highlight the robustness and versatility of RBMBs as a tool for imaging RNA in live cells. We envision that the unique capabilities of RBMBs will open up new avenues for RNA research.

Assessment of XPD Lys751Gln and XRCC1 T-77C polymorphisms in advanced non-small-cell lung cancer patients treated with platinum-based chemotherapy.

Polymorphisms in DNA repair genes were thought to represent important determinants of platinum drug efficacy. This study tested whether XPD Lys751Gln and XRCC1 T-77C polymorphisms were associated with survival in platinum-treated patients with advanced non-small-cell lung cancer (NSCLC). In this study, 199 advanced NSCLC patients with platinum-based chemotherapy were recruited. During the median 26.5 months of follow-up, patients with the XPD 751Lys/Lys genotype had a median survival time of 17.0 months (95% CI, 14.5-19.6 months), not much longer than those carried Lys/Gln heterozygote (12.0 months; 95% CI, 3.4-20.6 months; log-rank test, P=0.542). In Cox proportional hazards model, no significant associations were found between XPD Lys751Gln polymorphism and survival. For XRCC1 T-77C polymorphism, the median survival of patients with TC+CC genotype (18 months; 95% CI, 13.5-22.5 months) was similar to those with the TT genotype (16.0 months; 95% CI, 13.3-18.7 months; log-rank test, P=0.399). XRCC1 T-77C polymorphism was not associated with survival in Cox proportional hazards model. Additionally, the analysis for combination of these two polymorphisms also showed no prognostic significance for NSCLC. Our findings indicated that neither XPD Lys751Gln nor XRCC1 T-77C could be genetic determinant for prognosis of advanced NSCLC patients treated with platinum-based chemotherapy.

Genetic variation and conservation assessment of Chinese populations of Magnolia cathcartii (Magnoliaceae), a rare evergreen tree from the South-Central China hotspot in the Eastern Himalayas.

Nine natural populations of the rare evergreen tree Magnolia cathcartii (Magnoliaceae) were sampled across its natural range, and amplified fragment length polymorphism (AFLP) markers were used to assess genetic variation within and among populations. Three ex situ populations were also surveyed to determine whether conservation plantings include the entire genetic diversity of the species. Genetic diversity within the natural populations was very low (0.122 for Nei's gene diversity), and the southeast populations had the highest diversity. The ex situ populations had a lower diversity than the mean diversity for all populations, and none of the ex situ populations reached the levels of diversity found in their source populations. Genetic differentiation was high among natural populations (G st = 0.247), and an isolation-by-distance pattern was detected. Habitat fragmentation, restricted gene flow, and geitonogamy are proposed to be the primary reasons for the low genetic diversity and high genetic differentiation. More protection is needed, especially for the southeast populations, which possess the highest numbers of unique alleles according to AFLP fragment analyses. The ex situ program was a good first step towards preserving this species, but the current ex situ populations preserve only a limited portion of its genetic diversity. Future ex situ efforts should focus on enhancing the plantings with individuals from southeastern Yunnan.

Impact of admission-day crowding on the length of stay of pediatric hospitalizations.

OBJECTIVE: Increased crowding may affect the care that is delivered to hospitalized patients, particularly around the time of admission. There is little information about the impact of admission-day crowding on the outcome of children who are hospitalized with common pediatric conditions. METHODS: A population cohort was constructed of children who were aged 1 to 17 years and were hospitalized in Pennsylvania and New York between April 1, 1996, and June 30, 1998, with 1 of 19 common pediatric conditions (N = 116,235). Condition-specific Cox regression and logit models were developed to estimate the effect of admission-day occupancy on 4 outcome measures after controlling for illness severity and site of care: length of stay; 21-day readmission; prolonged stay or a stay longer than the typical, uncomplicated stay for that condition as a measure of care delivered to patients with uncomplicated courses; and conditional length of stay as a measure of care delivered to patients whose stays are prolonged. RESULTS: For children who were admitted with respiratory disease, increasing admission-day occupancy from 60% to 100% was associated with a 0.25-day increase in the average length of stay. Increased admission-day occupancy above 60% was also associated with higher odds of a prolonged stay but not with a change in 21-day readmission rates or conditional length of stay. For children who were admitted with nonrespiratory conditions, increased admission-day occupancy was not associated with changes to any length-of-stay outcome. CONCLUSIONS: Increased admission-day occupancy was associated with longer lengths of stay for less complicated respiratory admissions but not for children who were admitted with the most serious conditions. These results suggest that medical professionals, during times of increased workload, first focus their attention on more acutely ill children with a complicated course and thus delay treatment of children who have less complicated courses but require time-consuming management and treatment.

Estimating anesthesia and surgical procedure times from medicare anesthesia claims.

BACKGROUND: Procedure times are important variables that often are included in studies of quality and efficiency. However, due to the need for costly chart review, most studies are limited to single-institution analyses. In this article, the authors describe how well the anesthesia claim from Medicare can estimate chart times. METHODS: The authors abstracted information on time of induction and entrance to the recovery room ("anesthesia chart time") from the charts of 1,931 patients who underwent general and orthopedic surgical procedures in Pennsylvania. The authors then merged the associated bills from claims data supplied from Medicare (Part B data) that included a variable denoting the time in minutes for the anesthesia service. The authors also investigated the time from incision to closure ("surgical chart time") on a subset of 1,888 patients. RESULTS: Anesthesia claim time from Medicare was highly predictive of anesthesia chart time (Kendall's rank correlation tau = 0.85, P < 0.0001, median absolute error = 5.1 min) but somewhat less predictive of surgical chart time (Kendall's tau = 0.73, P < 0.0001, median absolute error = 13.8 min). When predicting chart time from Medicare bills, variables reflecting procedure type, comorbidities, and hospital type did not significantly improve the prediction, suggesting that errors in predicting the chart time from the anesthesia bill time are not related to these factors; however, the individual hospital did have some influence on these estimates. CONCLUSIONS: Anesthesia chart time can be well estimated using Medicare claims, thereby facilitating studies with vastly larger sample sizes and much lower costs of data collection.

Influence of patient and hospital characteristics on anesthesia time in medicare patients undergoing general and orthopedic surgery.

BACKGROUND: Procedure time is a clinically important variable that is often analyzed when studying quality and efficiency. Norms for procedure length have not been reported from Medicare data sets, nor has the influence of patient and hospital characteristics on procedure time been estimated using Medicare data. METHODS: The authors obtained Medicare claims on all patients aged 65-85 years who underwent general surgical and orthopedic surgical procedures in Pennsylvania. Anesthesia procedure time was estimated from anesthesia time units bills supplied from Medicare on 20 common general and orthopedic surgery procedures, and models to determine the influence of hospital and patient characteristics were developed. RESULTS: Of the 77,638 patients, 31,472 had general surgery and 46,166 underwent orthopedic procedures. The median anesthesia time for general surgery was 133 min, and for orthopedic surgery it was 146 min. After adjusting for principal procedure, hospital, and physiologic severity, covariates associated with increased anesthesia time included: multiple procedure on same day + 18.3 min (P < 0.0001); transfer-in + 6.7 min (P = 0.0002); black race + 5.5 (P < 0.0001); coagulation disorders + 4.9 (P = 0.0012); and paraplegia + 4.5 (P = 0.0006). Lower-income black patients had significantly longer procedure times than lower-income white patients (+ 7 min; P < 0.0001). Among the 15 hospitals with the largest black surgical populations, 5 hospitals had statistically significant procedure lengths for black versus white patients, ranging from + 9 to + 16 min. CONCLUSIONS: In addition to variation by patient comorbidities and procedure, anesthesia procedure time varies with hospital, medical history, and sociodemographic characteristics.