COVID-19 Impact on Vascular Surgery Practice: Experience From an Italian University Regional Hub Center for Vascular Pathology.

BACKGROUND: The aim of the study is to evaluate the impact of COVID-19 pandemic on vascular surgery practice in a regional hub center for complex vascular disease. METHODS: This is an observational single-center study in which we collected clinical and surgical data during (P1) and after (P2) the COVID-19 outbreak and the lockdown measures implemented in Northern Italy. We compared those data with the two-month period before the pandemic (P0). RESULTS: Compared to P0, ambulatory activities were severely reduced during P1 and limited to hospitalized patients and outpatients with urgent criteria. We performed 61 operations (18 urgent and 43 elective), with a decrease in both aortic (-17.8%), cerebrovascular (-53.3%), and peripheral artery (-42.6%) disease treatments. We also observed a greater drop in open procedures (-53.2%) than in endovascular ones (-22%). All the elective patients were treated for notdeferrable conditions and they were COVID-19 negative at the ward admission screening; despite this one of them developed COVID19 during the hospital stay. Four COVID-19 positive patients were treated in urgent setting for acute limb ischemia. Throughout P2 we gradually rescheduled elective ambulatory (+155.5%) and surgical (+18%) activities, while remaining substantially lower than during P0 (respectively -45.6% and -25.7%). CONCLUSIONS: Despite COVID-19 pandemic, our experience shows that with careful patient's selection, dedicated prehospitalization protocol and proper use of personal protective equipment it is possible to guarantee continuity of care.

Number of Patients with Ischemic Stroke did not Decline in a Regional Stroke Unit After the Implementation of Mechanical Thrombectomy.

OBJECTIVES: Since the implementation of mechanical thrombectomy (MT) in 2015 for patients with ischemic stroke and large-vessel occlusion, the question arose as to whether patients should be primarily admitted to the nearest regional stroke unit (SU) for prompt intravenous thrombolysis (IVT) or to a more distant supraregional SU performing MT, to avoid secondary-transfer delays in MT. Although an evidence-based answer is still lacking, a discrepant discussion with potential consequences for the regional flow of stroke patients arose. We aimed to assess if MT implementation was associated with the number and characteristics of patients with stroke/transient ischemic attack (TIA) admitted to a regional SU not offering endovascular treatment. MATERIALS AND METHODS: Patients with acute stroke/TIA treated at the Klinikum Main-Spessart Lohr, Germany, in 2013/2014 or 2017/2018 were included in this retrospective study. Data were derived from the clinical information system and mandatory stroke quality assessment. We assessed the catchment area using a region-based approach. For each region, the number of patients treated in our hospital, including data regarding clinical severity, demographic characteristics, and changes over time, were analyzed. RESULTS: The number of patients with acute stroke/TIA increased from 890 (2013/2014) to 1016 (2017/2018). Aggregated demographic and clinical data of the whole catchment area showed no differences between 2013/2014 and 2017/2018 (P > 0.05) besides duration of hospitalization (P < 0.01), IVT rate (P < 0.01), and secondary transfer for MT. A region-based analysis revealed an increase in younger and more severely affected patients admitted from the periphery of the catchment area between 2013/2014 and 2017/2018. CONCLUSION: Despite the implementation of MT in the supraregional SUs around our regional SU (not offering MT), more patients with stroke/TIA were admitted to our hospital, especially younger and more severely affected patients, from the border regions of the catchment area.

Cardiac surgery in North America and coronavirus disease 2019 (COVID-19): Regional variability in burden and impact.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in hospital resource utilization and the need to defer nonurgent cardiac surgery procedures. The present study aims to report the regional variations of North American adult cardiac surgical case volume and case mix through the first wave of the COVID-19 pandemic. METHODS: A survey was sent to recruit participating adult cardiac surgery centers in North America. Data in regard to changes in institutional and regional cardiac surgical case volume and mix were analyzed. RESULTS: Our study comprises 67 adult cardiac surgery institutions with diverse geographic distribution across North America, representing annualized case volumes of 60,452 in 2019. Nonurgent surgery was stopped during the month of March 2020 in the majority of centers (96%), resulting in a decline to 45% of baseline with significant regional variation. Hospitals with a high burden of hospitalized patients with COVID-19 demonstrated similar trends of decline in total volume as centers in low burden areas. As a proportion of total surgical volume, there was a relative increase of coronary artery bypass grafting surgery (high +7.2% vs low +4.2%, P = .550), extracorporeal membrane oxygenation (high +2.5% vs low 0.4%, P = .328), and heart transplantation (high +2.7% vs low 0.4%, P = .090), and decline in valvular cases (high -7.6% vs low -2.6%, P = .195). CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgery institutions as well as helps associate region and COVID-19 burden with the impact on cardiac surgery volumes and case mix.

Impact of COVID-19 outbreak on regional STEMI care in Germany.

AIMS: To assess the impact of the lockdown due to coronavirus disease 2019 (COVID-19) on key quality indicators for the treatment of ST-segment elevation myocardial infarction (STEMI) patients. METHODS: Data were obtained from 41 hospitals participating in the prospective Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) study, including 15,800 patients treated for acute STEMI from January 2017 to the end of March 2020. RESULTS: There was a 12.6% decrease in the total number of STEMI patients treated at the peak of the pandemic in March 2020 as compared to the mean number treated in the March months of the preceding years. This was accompanied by a significant difference among the modes of admission to hospitals (p = 0.017) with a particular decline in intra-hospital infarctions and transfer patients from other hospitals, while the proportion of patients transported by emergency medical service (EMS) remained stable. In EMS-transported patients, predefined quality indicators, such as percentages of pre-hospital ECGs (both 97%, 95% CI = - 2.2-2.7, p = 0.846), direct transports from the scene to the catheterization laboratory bypassing the emergency department (68% vs. 66%, 95% CI = - 4.9-7.9, p = 0.641), and contact-to-balloon-times of less than or equal to 90 min (58.3% vs. 57.8%, 95%CI = - 6.2-7.2, p = 0.879) were not significantly altered during the COVID-19 crisis, as was in-hospital mortality (9.2% vs. 8.5%, 95% CI = - 3.2-4.5, p = 0.739). CONCLUSIONS: Clinically important indicators for STEMI management were unaffected at the peak of COVID-19, suggesting that the pre-existing logistic structure in the regional STEMI networks preserved high-quality standards even when challenged by a threatening pandemic. CLINICAL TRIAL REGISTRATION: NCT00794001.

Nationwide survey on the current practice of ventricular tachycardia ablation.

METHODS: We performed a nationwide survey on the current practice of ventricular tachycardia catheter ablation in Italy during the year 2016. RESULTS: Among 145 operators participating in the survey, 58 (40.0%) did not perform any ventricular tachycardia ablation in 2016. Among those performing ventricular tachycardia ablation, 9 operators (6.2%) performed only right ventricular endocardial catheter ablation, 52 (35.9%) performed endocardial catheter ablation both in the right and left ventricle (LV) and 26 (17.9%) performed both endocardial and epicardial LV catheter ablations. Seventy operators (89.7%) among the 78 performing LV and epicardial ablations treated patients with ischemic cardiomyopathy; ablations in the setting of other causes were less frequently performed. The following were considered as minimum requirements for ventricular tachycardia ablation: presence of a three-dimensional mapping system (120 operators, 82.8%), ICU in the hospital (118 operators, 81.4%), operator's training in high volume centers (93 operators, 64.1%). Twenty-eight operators (19.3%) performed catheter ablation in patients with electrical storm only after hemodynamic stabilization, 41 operators (28.3%) also during the acute phase and 9 operators (6.2%) never performed catheter ablation in electrical storm patients; the remaining 67 operators did not perform ventricular tachycardia ablation at all, or performed ablations only in the right ventricle. CONCLUSION: The present survey provides a snapshot of the current invasive treatment of ventricular tachycardia by catheter ablation. The procedure, especially in the setting of ischemic cardiomyopathy, is performed nationwide. Complex cases, including those with electrical storm, should be managed within a preestablished integrated network of regional referral centers able to transfer patients as soon as possible.

Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees.

OBJECTIVE: The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. METHODS: A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. RESULTS: During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). CONCLUSIONS: In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

Regional variation in use and outcomes of combined carotid endarterectomy and coronary artery bypass.

OBJECTIVE: In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB. METHODS: All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χ2 analysis was performed. RESULTS: There were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P < .001). Regional variation in patch use (78% [W] to 93% [MW]; P < .001), shunting (29% [W] to 71% [MW]; P < .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P < .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75). CONCLUSIONS: Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.

Distribución de espacios verdes y actividades públicas gratuitas para realizar actividad física en la ciudad de Buenos Aires / Distribution of green spaces and public activities free for physical activity in the city of Buenos Aires

El sedentarismo está aumentando en la Ciudad Autónoma de Buenos Aires (CABA). Es importante estudiar el ambiente construido que promueve la realización de actividad física (AF). Nuestro objetivo fue analizar la distribución del espacio verde (EV) apto para realizar AF, así como la oferta estatal de actividades deportivas gratuitas en la ciudad. Se realizó un estudio ecológico analizando y mapeando datos según fuentes e informes oficiales de CABA para 2015. Hicimos un análisis por número absoluto, superficie, densidad poblacional y valor promedio del metro cuadrado construido por comuna. Además, realizamos un análisis cualitativo según imágenes satelitales de la ciudad. La mediana de espacio verde apto para AF era de 2,6 m2/habitante (rango intercuartílico de 1,0 a 4,6). La menor cantidad estuvo en las comunas céntricas, más densamente pobladas, así como en la mayoría de las de menor valor del terreno (una de estas tenía buena cantidad de EV, pero con un ambiente construido que podría limitar la realización de AF). En cambio, en cuanto a las actividades deportivas gratuitas, a menor valor del terreno había mayor oferta. Estos resultados deben analizarse junto con condiciones ambientales y de seguridad para la planificación integral de la ciudad. (AU)

Sedentary lifestyle is increasing in Buenos Aires City (CABA). It is important to study the built environment that promotes physical activity (PA). Our objective was to analyze the distribution of the green spaces or urban open spaces (GS) suitable for PA, as well as the state offer of free sports activities in the city. We did an ecological study, analyzing and mapping data according to sources and official reports of CABA for 2015. We performed analyses by absolute number, area, population density and average value of the built squared meter for each district (comuna). In addition, we did a qualitative analysis according to satellite images of the city. The median of green space suitable for PA was 2.6 m2 / inhabitant (interquartile range 1.0 to 4.6). The smallest amount was in the central districts, more densely populated, as well as in most of the lower landvalue ones (one of these had a good amount of GS, but with a built environment that could limit the practice of PA). In contrast, regarding free sports activities, the lower the value of the land, the greater the state offer. These results must be analyzed along with environmental and safety conditions for an integral planning of the city. (AU)

Geographic disparities in liver supply/demand ratio within fixed-distance and fixed-population circles.

Recent OPTN proposals to address geographic disparity in liver allocation have involved circular boundaries: the policy selected 12/17 allocated to 150-mile circles in addition to DSAs/regions, and the policy selected 12/18 allocated to 150-mile circles eliminating DSA/region boundaries. However, methods to reduce geographic disparity remain controversial, within the OPTN and the transplant community. To inform ongoing discussions, we studied center-level supply/demand ratios using SRTR data (07/2013-06/2017) for 27 334 transplanted deceased donor livers and 44 652 incident waitlist candidates. Supply was the number of donors from an allocation unit (DSA or circle), allocated proportionally (by waitlist size) to the centers drawing on these donors. We measured geographic disparity as variance in log-transformed supply/demand ratio, comparing allocation based on DSAs, fixed-distance circles (150- or 400-mile radius), and fixed-population (12- or 50-million) circles. The recently proposed 150-mile radius circles (variance = 0.11, P = .9) or 12-million-population circles (variance = 0.08, P = .1) did not reduce the geographic disparity compared to DSA-based allocation (variance = 0.11). However, geographic disparity decreased substantially to 0.02 in both larger fixed-distance (400-mile, P < .001) and larger fixed-population (50-million, P < .001) circles (P = .9 comparing fixed distance and fixed population). For allocation circles to reduce geographic disparities, they must be larger than a 150-mile radius; additionally, fixed-population circles are not superior to fixed-distance circles.

Estudio multicéntrico. Factores que influyen en la elección de carrera en Atención Primaria en estudiantes de último año de medicina o en servicio social en Centroamérica. Evidencia para fortalecer la Planificación de Recursos Humanos en la Subregión / Multicenter study: Factors that influence the election of a Primary Care career in senior medical or social service students in Central America. Evidence to strengthen Human Resource Planning in the Sub-region

El presente estudio multicéntrico identifica las especialidades médicas y prácticas preferidas en Centroamérica y los factores que inciden en dicha elección. Se pretende contribuir a iluminar una realidad que seguramente contribuirá a la definición de estrategias para fortalecer la Planificación de Recursos Humanos para la Salud en la Subregión y la definición de política pública de recursos humanos para la salud.

Estado de avance de la carrera sanitaria. Centroamérica y República Dominicana / Progress status of the Central American and Dominican Republic health career

El presente documento constituye un esfuerzo de análisis y sistematización de los avances y desafíos en el desarrollo de la carrera sanitaria en la Subregión, al igual que propone una ruta por etapas que tiene por objetivo contar con una guía que permita avanzar en el tema, en un momento de cambios políticos en varios de los países de la Subregión.

Strengthening primary care: The Veneto Region's model of the Integrated Medical Group.

PURPOSE: This paper aims to illustrate the development of the Veneto Region's (Italy) new primary care model and to report on the preliminary results. BACKGROUND: Achieving integrated management and continuity of care are the two main aims of the Veneto Region's health planning legislation for 2012-2016. Under this framework, and to meet new emerging population needs, it has become necessary to adopt a new primary care model that embraces multi-professional teams. In response the Veneto Region has developed the Integrated Medical Group (IMG), launched in 2016. The Integrated Medical Group is an innovative model at both the regional and national level and represents a key element of the health care system. It targets several goals: it provides more effective care than in the past; guarantees services within the region while optimizing the use of resources, through integrated patient care and its accompanying care pathways; it builds dialogue between hospitals and community based primary care services; develops relationships of trust between doctors and patients, pursuing shared team goals and enhances the different skills and roles of their constituent members. Regional legislation sets challenging objectives, stating that by the end 2017, 60% of all GPs in the region should conduct their activities as part of an IMG, with a further target of 80% by the end 2018.

CD56/10: Plan de acción sobre recursos humanos para el acceso universal a la salud y la cobertura universal de salud 2018-2023 / Plan of action on human resources for universal access to health and universal health coverage 2018-2023

La 29.ª Conferencia Sanitaria Panamericana aprobó en septiembre del 2017 la Estrategia de recursos humanos para el acceso universal a la salud y la cobertura universal de salud (documento CSP29/10) (1). En la resolución aprobada (CSP29.R15) (2), se solicita a la directora elaborar para el año 2018 un plan de acción regional con objetivos específicos e indicadores, a fin de avanzar de manera más expedita en la ruta establecida en dicha estrategia. (AU)

Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014.

BACKGROUND: The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery. METHODS: A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants. RESULTS: The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 ± 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 ± 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency. CONCLUSION: Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.

Regional healthcare delivery and demographic change in Germany - scenarios for dermatological care in 2035.

BACKGROUND: The 'demand planning guidelines' issued by the Federal Joint Committee are meant to ensure nationwide delivery of healthcare in Germany. The calculatory variable used to reflect the actual care situation in relation to a given geographical entity is referred to as 'adjusted supply rate'. Against the backdrop of demographic change and already existing problems in replacing retiring physicians, the question arises as to how future dermatological care will evolve at the regional level. METHODS: Using current 'demand planning guidelines' as well as nationwide data on the location of dermatologists and current and projected population figures at the county level, the adjusted supply rate - in terms of dermatological care - was calculated for the year 2035 based on three possible scenarios (scenario 1: 100 % replacement of retiring dermatologists; scenario 2: non-replacement of one dermatologist per planning area; and scenario 3: non-replacement of two dermatologists in rural areas). RESULTS: While scenario 1 shows an actual improvement in regional dermatological care in certain areas between 2014 and 2035 (n = 3 no longer undersupplied), the more likely scenarios 2 and 3 are potentially associated with considerable regional undersupply. CONCLUSIONS: Taking demographic change into account, it is safe to assume that the geographical heterogeneity of dermatological care will increase. This requires greater effort not only in terms of demand planning but also with regard to offering alternative methods of delivering healthcare and intercommunal cooperation. In this context, the objective will be to adapt healthcare delivery to changes both in demography as well as in the plans young physicians have for their own lives.

Population-Based Analysis and Projections of Liver Supply Under Redistricting.

BACKGROUND: To reduce the geographic heterogeneity in liver transplant allocation, the United Network of Organ Sharing has proposed redistricting, which is impacted by both donor supply and liver transplantation demand. We aimed to determine the impact of demographic changes on the redistricting proposal and characterize causes behind geographic heterogeneity in donor supply. METHODS: We analyzed adult donors from 2002 to 2014 from the United Network of Organ Sharing database and calculated regional liver donation and utilization stratified by age, race, and body mass index. We used US population data to make regional projections of available donors from 2016 to 2025, incorporating the proposed 8-region redistricting plan. We used donors/100 000 population age 18 to 84 years (D/100K) as a measure of equity. We calculated a coefficient of variation (standard deviation/mean) for each regional model. We performed an exploratory analysis where we used national rates of donation, utilization and both for each regional model. RESULTS: The overall projected D/100K will decrease from 2.53 to 2.49 from 2016 to 2025. The coefficient of variation in 2016 is expected to be 20.3% in the 11-region model and 13.2% in the 8-region model. We found that standardizing regional donation and utilization rates would reduce geographic heterogeneity to 4.9% in the 8-region model and 4.6% in the 11-region model. CONCLUSIONS: The 8-region allocation model will reduce geographic variation in donor supply to a significant extent; however, we project that geographic disparity will marginally increase over time. Though challenging, interventions to better standardize donation and utilization rates would be impactful in reducing geographic heterogeneity in organ supply.

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study.

BACKGROUND: The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan. METHODS: We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012. RESULTS: The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a - 15% change. The extent of decline was largest in the North region (from 27% to 21%, a - 22% change) and least in Kaopin region (from 20% to 18%, a - 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%. CONCLUSIONS: In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

[Regional Budgets in Psychiatry: An Alternative to Hospital per Diem Charges and the New Reimbursement System? - A Case Study from the District of Dithmarschen]. / Regionalbudgets in der Psychiatrie: Eine Alternative zu tagesgleichen Pflegesätzen und zum zukünftigen Finanzierungssystem?

Objective The study looked at the impact that the switch from a reimbursement system with hospital per diem charges to a regional budget had on treatment. Methods Routine data from two clinics over a period of ten years were evaluated. Results Treatment took place in day clinics and on an outpatient basis to an increased extent after the change. Conclusion The change in reimbursement system was the cause of the change in treatment. Since similar effects can also be expected when switching from the new reimbursement system for psychiatry and psychosomatic medicine to a regional budget system, regional budgets are a reasonable alternative.