Telestroke.

PURPOSE OF REVIEW: This study aims to describe the current state of telestroke clinical applications and policies, in addition to key technical and operational aspects of the telemedicine practice. RECENT FINDINGS: Delivery of telestroke services for neurovascular care expanded from the intravenous alteplase decision and administration in acute emergency department settings to a continuum of services in mobile and inpatient stroke units, intensive care units, virtual stroke clinics, rehabilitation, and clinical research. Telestroke cost-effectiveness is well established from multiple perspectives. Stroke centers, certification agencies, and national registries have made essential recommendations regarding telestroke quality measures monitoring and reporting. Telestroke continues to bring neurovascular expertise to resource-restricted areas with advanced virtual communication techniques, optimizing stroke care. Future research should aim at broadening telestroke technology applications, while improving quality and reducing the delivery-associated cost and resources. Comprehensive multidisciplinary virtual telestroke centers that cover all aspects of stroke management might become available in the future.

Follow Your Heart: Survival Chances and Costs after Heart Attacks-An Instrumental Variable Approach.

OBJECTIVE: To determine the effect of heart attack patients' access to intensive treatment on mortality and costs. DATA SOURCES: Administrative data of 4,920 patients with acute myocardial infarction from the Austrian Social Security Database and the Upper Austrian Sickness Fund for the period 2002-2011. STUDY DESIGN: As treatment intensity in a hospital largely depends on whether it has a catheterization laboratory, we explore the effects of patients' initial admission to such specialized percutaneous coronary intervention (PCI) hospitals. To account for the nonrandom selection of patients into hospitals, we exploit individuals' place of residence as a source of exogenous variation in an instrumental variable framework. PRINCIPAL FINDINGS: We find that the initial admission to PCI hospitals increases patients' survival chances substantially. The effect on 3-year mortality is -9.5 percentage points. Subgroup analysis shows the strongest effects in relative terms for patients below the age of 65. We do not find significant effects on long-term inpatient costs and only marginal increases in outpatient costs. CONCLUSIONS: Our findings suggest that place of residence affects the access of patients to invasive heart attack treatment and therefore their chance of survival. We conclude that that providing more patients immediate access to PCI hospitals should be beneficial.

Are suspected stroke patients identified by paramedics transported to appropriate stroke centres in Victoria, Australia?

Emergency medical services (EMS) are vital to ensuring acute stroke patients are transported to thrombolysis and/or stroke unit centres. This 6-month audit of Victorian EMS cases found the majority of suspected acute strokes are transported to appropriate stroke centres. However, there is still room for improvement, in particular, strategies to improve access to stroke services in some rural regions and to ensure patients/relatives are fully informed when requesting transport to a non-stroke service hospital.

Hematopoietic cell transplantation for thalassemia: a global perspective BMT tandem meeting 2013.

Hematopoietic cell transplantation (HCT) remains the sole available curative option for patients with ß-thalassemia major. Expanded and improved supportive therapies for thalassemia now routinely extend the life span of affected individuals well into adulthood. Consequently, in regions of the world where this care is readily available, HCT has been pursued infrequently, in part owing to concerns about an expected lack of balance between risks and benefits. More recently, however, recognition of significant health problems in older patients with thalassemia, along with recognition of increased risks of graft-versus-host disease (GVHD), graft rejection, and impaired organ function leading to inferior HCT outcomes in this particular group, seem to be turning the wheels and tipping the balance again in the direction of consideration for earlier HCTs. In contrast, in countries where thalassemia is most prevalent (>100,000 new children born each year in Middle East and southeast Asia), lack of supportive care standards together with often insufficient access to dedicated health care facilities, results in the majority of these children not reaching adulthood, further supporting the need for expanded access to HCT for these patients. The cost of HCT is equivalent to that of a few years of noncurative supportive care, such that HCT in low-risk young children with a compatible sibling is justified not only medically and ethically but also financially. International cooperation can play a major role in increasing access to safe and affordable HCT in countries where there is a considerable shortage of transplantation centers. In this article, we review the current status of bone marrow transplantation for thalassemia major, with particular emphasis on a global prospective.

Allogeneic transplant physician and center capacity in the United States.

Shortage of manpower and center capacity is expected to be a major challenge to the anticipated future growth in the utilization of allogeneic hematopoietic cell transplantation (HCT) in the United States. Using data from the National Marrow Donor Program's Transplant Center Network Renewal Survey, we describe transplant center and transplant physician capacity in the United States from 2005 to 2009. Over this 5-year period, the number of allogeneic transplants increased by 30%, bed capacity increased by 17%, and physician full-time equivalents increased by 26%. The number of related donor HCT increased by 15% and unrelated donor HCT increased by 45%. In addition to large centers, small- and medium-sized centers also made a major contribution to overall national transplant volumes for both related and unrelated donor HCT. Increase in utilization of unrelated donor HCT occurred in centers irrespective of their size. The majority of transplant centers were performing more transplantations using existing physician and bed capacity. Our study provides important descriptions of allogeneic transplant activity and capacity of U.S. centers, and our data will assist policy makers plan for the projected growth in the use of transplantation.

[Medical and surgical health care for congenital heart disease: a panoramic vision of the reality in Mexico. Inquiry 2009]. / Atención médico-quirúrgica de las cardiopatías congénitas: una visión panorámica de la realidad en México. Encuesta 2009.

INTRODUCTION: The only way to characterize the Mexican problem related to congenital heart disease care is promoting the creation of a national database for registering the organization, resources, and related activities. MATERIAL AND METHODS: The Health Secretary of Mexico adopted a Spanish registration model to design a survey for obtaining a national Mexican reference in congenital heart disease. This survey was distributed to all directors of medical and/or surgical health care centers for congenital heart disease in Mexico. This communication presents the results obtained in relation to organization, resources and activities performed during the last year 2009. RESULTS: From the 22 health care centers which answered the survey 10 were reference centers (45%) and 12 were assistant centers (55%). All of them are provided with cardiologic auxiliary diagnostic methods. Except one, all centers have at least one bidimentional echocardiography apparatus. There is a general deficit between material and human resources detected in our study. Therapeutic actions for congenital heart disease (70% surgical and 30% therapeutical interventionism) show a clear centralization tendency for this kind of health care in Mexico City, Monterrey and finally Guadalajara. CONCLUSIONS: Due to the participation of almost all cardiac health centers in Mexico, our study provides an important information related to organization, resources, and medical and/or surgical activities for congenital heart disease. The data presented not only show Mexican reality, but allows us to identify better the national problematic for establishing priorities and propose solution alternatives.

Tertiary eye care centre model for development of paediatric cataract surgery services in developing countries.

It is estimated that every minute a child becomes bilaterally blind in developing nations. Paediatric cataract blindness presents an enormous problem to developing countries in terms of the human social burden, economic loss, and morbidity. The management of the paediatric cataract is lens aspiration with intra ocular lens implantation with anterior vitrectomy. The surgery should be performed by paediatric ophthalmologist in tertiary eye care centres. Facilities of general anaesthesia should be available in these centres and the operating theatres should be well-equipped with vitrectomy machine, biometry and portable keratometer.

Should physician-owned single-specialty hospitals continue to exist?

Physician-owned single-specialty hospitals (SSHs) account for only about 200 hospitals out of approximately 5500 hospitals nationwide, and yet they are at the center of a raging debate. The ability of community SSHs to lower costs and improve quality while threatening the viability and existence of community full-service hospitals is at the center of the hotly contested debate. A review of prior studies on this issue does not reveal competitiveness in the marketplace between SSHs and community full-service hospitals. In fact, the debate on the relatively newness of SSHs creates a number of questions not entirely answered by the research, which prevents a real understanding of their value to society and thus a resolution of the raging debate.

Drive-time proximity to Joint Commission Primary Stroke Centers among North Carolina residents who died of stroke.

OBJECTIVE: In developing a statewide system of stroke care, understanding the relative availability of acute stroke care at designated centers for stroke care is essential. In this article, we compare the change in availability of acute stroke care in North Carolina at Joint Commission Primary Stroke Centers (JCPSCs) between 2006 and 2008 by examining the drive-time proximity of the residential address to the nearest JCPSC among people who died of stroke. METHODS: We assigned geographic coordinates to residential addresses of North Carolinians who died of stroke and to addresses of North Carolina JCPSCs. We calculated the distance within a 40-minute drive from each JCPSC and determined whether the residential addresses of patients who died of stroke were in the areas demarcated by the drive time. In a secondary analysis, we included non-ICPSCs that participate in recognized quality-improvement programs for stroke care. RESULTS: In 2006, 37% of geocodable residences of patients who died of stroke (3,834 of 10,469) were within a 40-minute drive from a JCPSC. By the end of 2008, this percentage increased to 56% (3,482 of 6,204). Inclusion of other hospitals that participate in recognized quality-improvement programs for acute stroke care increased the 40-minute drive-time coverage to 82% (5,095 of 6,204). LIMITATIONS: As an index of the geographic distribution of the stroke burden, we used deaths due to stroke, rather incident strokes. We included several assumptions in our drive-time calculation. CONCLUSIONS: For many regions of North Carolina in which the stroke burden is high, timely care at JCPSCs for acute stroke is unavailable. To develop a statewide system for acute stroke care in North Carolina, criteria beyond JCPSC certification should be considered for designating hospitals as centers for stroke care.

Status of pediatric eye care in India.

PURPOSE: To document the status of pediatric eye care in India. MATERIALS AND METHODS: A list of institutions providing eye care was compiled from various sources, including government officials, professional bodies of ophthalmologists, and national and international non-governmental organizations (NGO) working in the field of eye care in India. A questionnaire on eye care services was sent to all known eye care institutions in the country. Workshops and regional meetings were organized to maximize response. Validity of data was ensured by observational visits to 10% of the institutions who responded. RESULTS: Out of 1204 institutions contacted, 668 (55.5%) responded to the questionnaire. Of these, 192 (28.7%) reported that they provided pediatric eye care services. A higher proportion (48.3%) of NGO hospitals reported separate pediatric ophthalmology units compared to other providers (P< 0.001). Eighty per cent of advanced care eye hospitals had dedicated outpatient, and 40% had dedicated inpatient facilities for children (P< 0.001). The advanced eye care hospitals attended to a larger number of pediatric clients (P < 0.001), and performed more pediatric eye surgeries compared to secondary and tertiary care hospitals (P < 0.001). Eighty-three per cent of advanced care centers and 72.4% of NGO hospitals had an anesthesiologist for pediatric eye service. Refractive error was the commonest reason for seeking service. The commonest surgical procedure was pediatric cataract surgery followed by squint surgery. CONCLUSION: Pediatric eye care services are not adequate in India.

Public policy regarding specialty hospitals.

Why do we need "public policy" regarding specialty hospitals? What is the rationale for government involvement in decisions by the private sector to invest in specialty hospitals? Two possibilities are reduced access to services primarily by the uninsured (a fairness concern) and changes in the types of patients receiving care resulting from poor consumer information (an efficiency concern). The fairness argument faces logical and empirical difficulties, and even if it proved to be true, it is not clear that limiting the growth of specialty hospitals would be an efficient way to address the problem. However, there is some empirical evidence to support the efficiency concern, and if specialty hospitals result in the treatment of patients with lower expected net benefits from treatment, then it is possible that physician-owned facilities could result in an increasingly inefficient allocation of health care resources, higher insurance premiums, and higher rates of uninsurance.

A survey of memory clinics in New Zealand.

OBJECTIVE: The aim of this survey was to identify all the publicly funded memory clinics in the 21 District Health Boards (DHBs) in New Zealand. METHOD: Information on the provision of memory clinics was obtained by emailing the old age psychiatrists' group and making telephone contact with clinicians working in old age psychiatry/geriatric services. A brief structured questionnaire was completed by the memory clinic lead clinicians. RESULTS: There are eight memory clinics in New Zealand, funded equally between mental health services and geriatric medicine. However, there is variability in the provision of memory clinics in the medium and smaller sizedDHBs and inconsistency in the level of funded staff across DHBs. CONCLUSIONS: Acknowledgement of the value of memory clinics within a national service framework is needed, with appropriate benchmarking of funding. This would ensure improved access, including for rural and remote areas of New Zealand.