Magnetic resonance imaging (MRI) utilization in a Ghanaian teaching hospital: trend and policy implications.

BACKGROUND: The use of Magnetic Resonance Imaging (MRI) is new in Ghana compared with some Western countries. A number of studies have observed increased MRI utilization due to increased sensitivity to diagnosis, and the paradigm shift to modalities that do not use radiation. Challenges with MRI use include high cost of the examination and inappropriate requests by referring clinicians. OBJECTIVE: To determine the MRI utilisation trend in Korle Bu Teaching Hospital (KBTH), Ghana and its policy implications. MATERIALS AND METHODS: A retrospective study undertaken in the Radiology Department, KBTH, from February to March, 2017. Eight hundred and forty request forms for MRI studies between January, 2013 and December 2016 were reviewed. Information on patient's age and sex, number of MRI studies done, body parts and clinical conditions evaluated, appropriateness of clinical requests and existing policies on MRI in Ghana was gathered. Measures of central tendency and spread were obtained. Chi square, Pearson's correlation and linear regression analysis were also used in the analysis. RESULTS: The top three body parts requested were Spine (55 %), Brain (19%) and Joints (6 %); degenerative disease was the most common clinical condition evaluated.Significant association and correlation were obtained between of the number of body parts evaluated and examination year as well as the variety of clinical conditions requested and examination year. CONCLUSION: A progressive increase was noted in MRI utilisation both in number and diversity but no policy guiding MRI use in Ghana exists. FUNDING: None declared.

Patterns, Policy and Appropriateness: A 12-Year Utilization Review of Blood Glucose Test Strip Use in Insulin Users.

OBJECTIVES: Considerable attention has been paid to the rising costs of the use of blood glucose test strips (BGTS). Insulin users have generally been treated as a single homogeneous group, resulting in policies that cap usage (8.2 strips/day) in provincial drug insurance programs. The objective of this study was to conduct a utilization review of BGTS by insulin users and to evaluate use patterns against current insulin use patterns and BGTS policy. METHODS: BGTS usage was examined in a cohort of insulin users with type 1 and type 2 diabetes over a 12-year period (2001 to 2013) using the population-based administrative data in Manitoba, Canada. RESULTS: Total BGTS strip use increased by 121%, from $4.3 to $9.5 million. However, the number of insulin users also increased by 115%. Use has been stable at 1.5 strips per day per person since 2004 by insulin users with type 2 diabetes but has risen from 1.9 to 3.0 strips per day per person in those with type 1 diabetes. Mean daily test strip use was below the number of daily tests recommended for patients using insulin as per the current Canadian guidelines, with 11% and 15% of insulin users with type 1 and type 2 diabetes not claiming any BGTS use and a further 15% (type 1) and 28% (type 2) using fewer than 1 strip per day. CONCLUSIONS: BGTS use per insulin user has been stable for most of the past decade, and the vast majority of use falls well below provincial insurance caps. The amount of low-level testing (0 to <1 strip/day) suggests that greater attention should be directed to ensuring a safe level of testing by all insulin users.

Temporal Trends in Utilization of Transthoracic Echocardiography for Common Outpatient Pediatric Cardiology Diagnoses over the Past 15 Years.

BACKGROUND: No data exist regarding the temporal trends in utilization of transthoracic echocardiography (TTE) in an outpatient pediatric cardiology setting. This study evaluates the trends in utilization of TTE for common diagnoses known to have low diagnostic yield and the factors influencing these trends. METHODS: Patients evaluated at our pediatric cardiology clinics from January 2000 to December 2014 and discharged with final diagnoses of innocent murmur, noncardiac chest pain, benign syncope, and palpitations were included. Variables collected retrospectively included patient age, sex, insurance type, distance from clinic, and ordering physician's years of experience since fellowship. RESULTS: Of the 74,881 patients seen by 35 physicians, 36,053 (48.1%) had a TTE. The TTE rates increased from the beginning of 2000 to the end of 2004 (5.2% per year; P < .001) and then steadily declined until the end of 2014 (1.6% per year; P < .001). Utilization for noncardiac chest pain remained the highest, and use in infants increased significantly during the study period (P < .001). After adjusting for all other factors, the following variables were associated with higher TTE utilization: younger age, males, Medicaid insurance, increased distance from clinic, and being seen by less experienced physicians. Temporal trends persisted after adjusting for all these factors. CONCLUSIONS: After an initial surge in TTE utilization from 2000 to 2004, there was a steady decline. This study identifies some important factors influencing these trends. This information could help design quality interventions, but additional factors need to be explored since the trends persist despite adjusting for these factors.

[Materials/Biomaterials in Clinical Practice - a Short Review and Current Trends]. / Werkstoffe/Biomaterialien in der interventionellen und operativen Medizin ­ eine kurze Übersicht und aktuelle Trends.

Biomaterials play a major role in interventional medicine and surgery. However, the development of biomaterials is still in its early phases in spite of the huge progress made within the last decades. On the one hand, this is because our knowledge of the molecular and cellular processes associated with biomaterials is still increasing exponentially. On the other hand, a wide variety of advanced materials with highly interesting properties is being developed currently. This review provides a short introduction into the variety of materials in use as well as their application in interventional medicine and surgery. Also the importance of biomaterials for tissue engineering in the field of regenerative medicine and the functionalisation of biomaterials, including sterilisation methods are discussed. For the future, an even broader interdisciplinary scientific collaboration is necessary in order to develop novel biomaterials and facilitate their translation into clinical practice.

Trends in epilepsy surgery: stable surgical numbers despite increasing presurgical volumes.

INTRODUCTION: Despite the success of epilepsy surgery, recent reports suggest a decline in surgical numbers. We tested these trends in our cohort to elucidate potential reasons. PATIENTS AND METHODS: Presurgical, surgical and postsurgical data of all patients undergoing presurgical evaluation in between 1990 and 2013 were retrospectively analysed. Patients were grouped according to the underlying pathology. RESULTS: A total of 3060 patients were presurgically studied, and resective surgery was performed in 66.8% (n=2044) of them: medial temporal sclerosis (MTS): n=675, 33.0%; benign tumour (BT): n=408, 20.0%; and focal cortical dysplasia (FCD): n=284, 13.9%. Of these, 1929 patients (94.4%) had a follow-up of 2 years, and 50.8% were completely seizure free (Engel IA). Seizure freedom rate slightly improved over time. Presurgical evaluations continuously increased, whereas surgical interventions did not. Numbers for MTS, BT and temporal lobe resections decreased since 2009. The number of non-lesional patients and the need for intracranial recordings increased. More evaluated patients did not undergo surgery (more than 50% in 2010-2013) because patients were not suitable (mainly due to missing hypothesis: 4.5% in 1990-1993 up to 21.1% in 2010-2013, total 13.4%) or declined from surgery (maximum 21.0% in 2010-2013, total 10.9%). One potential reason may be that increasingly detailed information on chances and risks were given over time. CONCLUSIONS: The increasing volume of the presurgical programme largely compensates for decreasing numbers of surgically remediable syndromes and a growing rate of informed choice against epilepsy surgery. Although comprehensive diagnostic evaluation is offered to a larger group of epilepsy patients, surgical numbers remain stable.

Trends in the utilization of nuclear medicine and radiopharmaceuticals in an aging population.

AIM: To investigate the trends in the utilization of nuclear medicine procedures and radiopharmaceuticals in an aging population and to establish the prediction models. METHODS: Based on Taiwan's National Health Insurance Research Database, a longitudinal study was conducted from 2000 to 2012. Descriptive statistics were adopted to analyze the frequencies and distributions of nuclear medicine procedures. Multiple linear regression analysis was applied to establish the prediction model for the utilization of nuclear medicine. RESULTS: The utilization of myocardial perfusion imaging increased most significantly, i.e. 250 per million population (pmp) increment annually, followed by the whole-body bone scan (176 pmp) and whole-body PET scan (100 pmp) in Taiwan during the period of 2000-2012. The use rate of nuclear medicine procedure which the first quartile (Q1) of age at examination above 35 years fits the regression model: Use rate expected year = 0.03 Q1 of age at examination × use rate baseline year + 14797 life expectancy expected year / life expectancy baseline year - 15030. Adversely, the use rate of procedure which Q1 of age at examination below 35 years fits the model: Use rate expected year = 0.01 Q1 of age at examination × use rate baseline year - 4565 life expectancy expected year / life expectancy baseline year + 4749. In addition, the similar models were found in the applications of radiopharmaceuticals. CONCLUSION: This study demonstrates the age at examination and life expectancy can be used to predict the utilities of nuclear medicine procedures and radiopharmaceuticals in an aging population. Nuclear medicine practice applied in the geriatrics would increase significantly with the aging of population.

[Evaluation of a Self-Help Supported Counseling Concept for Children and Adolescents with Disproportional Short Stature]. / Evaluation eines selbsthilfegestützten psychosozialen Interventionsangebotes für Kinder und Jugendliche mit disproportionalem Kleinwuchs.

BACKGROUND: Disproportionate short stature may impair the quality of life (QoL) of patients and their families. This study aimed to evaluate a self-help supported counseling concept to increase the QoL of the participants. METHODS: QoL data from 58 children/adolescents (8-17 years) with a diagnosis of achondroplasia was collected at 2 measurement points during one year using the the QoLISSY questionnaire (self-/parental report). Differences before and after participation vs. non-participation in the intervention were evaluated using a linear mixed model. RESULTS: The longitudinal results show a greater increase of QoL in the active intervention group compared to a passive control group (p=0,005). The increase in the self-reported QoL of affected patients was significantly higher than for the parent-report (p=0,048). CONCLUSIONS: The study shows that patients with achondroplasia benefit from a self-help supported counseling concept. However, this should be tested in a randomized trial.

Increase in Utilization of Afterhours Medical Imaging: A Study of Three Canadian Academic Centers.

OBJECTIVES: The objectives of our study were to assess trends in afterhours medical imaging utilization for emergency department (ED) and inpatient (IP) patient populations from 2006-2013, including analysis by modality and specialty and with adjustment for patient volume. METHODS: For this retrospective study, we reviewed the number of CT, MRI, and ultrasound studies performed for the ED and IP patients during the afterhours time period (5pm - 8am on weekdays and 24 hours on weekends and statutory holidays) from 2006-2013 at three different Canadian academic hospitals. We used the Jonckheere-Terpstra (JT) test to determine statistical significance of imaging and patient volume trends. A regression model was used to examine whether there was an increasing trend over time in the volume of imaging tests per 1000 patients. RESULTS: For all three sites from 2006-2013 during the afterhours time period: There was a statistically significant increasing trend in total medical imaging volume, which also held true when the volumes were assessed by modality and by specialty. There was a statistically significant increasing trend in ED and IP patient volume. When medical imaging volumes were adjusted for patient volumes, there was a statistically significant increasing trend in imaging being performed per patient. CONCLUSION: Afterhours medical imaging volumes demonstrated a statistically significant increasing trend at all three sites from 2006-2013 when assessed by total volume, modality, and specialty. During the same time period and at all three sites, the ED and IP patient volumes also demonstrated a statistically significant increasing trend with more medical imaging, however, being performed per patient.

Health implications of a changing climate.

For the past five years, staff from the Minnesota Department of Health's Minnesota Climate and Health Program have been studying climate data and the potential health effects of climate change in the state. This year they released the "Minnesota Climate and Health Profile Report 2015," which presents a synthesis of their research. This article summarizes key points from that report.

Psychiatric emergency services in Copenhagen 2012: A 27-year psychiatric and demographic follow-up study.

BACKGROUND: Since the first publication of the psychiatric emergency units (PEUs) in Copenhagen 1985, outpatient facilities have undergone considerable changes. Our aim is to examine how these changes have influenced the activities in the PEUs in the same catchment area. METHODS: We conducted a follow-up study to describe this development in the past 27 years by comparing 1985 variables with same measures in 2012. A random sample of all visits every 10 days in 2012 to three PEUs in Copenhagen were registered and compared with data collected, using the same study design in 1985. MAIN RESULTS: The number of visits has decreased significantly from 367 visits/year/10,000 inhabitants in 1985 to 225 in 2012. Apart from a considerable number (15.6%) of visitors with non-Danish background, the demographic variables have not changed significantly since 1985. Compared with 1985, the diagnostic distribution among the 2012 visitors shows an increased frequency of affective disorders and neurotic and stress disorders, while schizophrenia spectrum and personality disorders show almost the same frequencies in 1985 and 2012. Rates of alcoholism and organic mental disorders show a minor reduction during the 27-year follow-up period. In 1985, 20.7% of the visits ended up without any referrals, compared with 4.8% in 2012. The rate of acute admissions into a psychiatric ward was 60.8% in 2012 compared with 35.65% in 1985. CONCLUSION: The extension of the psychiatric outpatients' facilities since 1985 has reduced the number of visits in the PEUs considerably. The results have shown a change of diagnostic distribution and more severe conditions requiring acute admissions for emergency treatment. Close collaboration with the patients' families, GPs, social authorities and specialized psychiatric outpatient clinics is emphasized.

Nearly half of all Medicare hospice enrollees received care from agencies owned by regional or national chains.

Analyses of ownership in the US hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000-11, we tracked the evolution of the US hospice industry. We not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, our analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace.

Expectations about future use of long-term services and supports vary by current living arrangement.

Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages 40-65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was "very likely" that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60 percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70 percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.

At least half of new Medicare advantage enrollees had switched from traditional Medicare during 2006-11.

With ongoing interest in rising Medicare Advantage enrollment, we examined whether the growth in enrollment between 2006 and 2011 was mainly due to new beneficiaries choosing Medicare Advantage when they first become eligible for Medicare. We also examined the extent to which beneficiaries in traditional Medicare switched to Medicare Advantage, and vice versa. We found that 22 percent of new Medicare beneficiaries elected Medicare Advantage over traditional Medicare in 2011; they accounted for 48 percent of new Medicare Advantage enrollees that year. People ages 65-69 switched from traditional Medicare to Medicare Advantage at higher-than-average rates. Dual eligibles (people eligible for both Medicare and Medicaid) and beneficiaries younger than age sixty-five with disabilities disenrolled from Medicare Advantage at higher-than-average rates. On average, in each year of the study period we found that fewer than 5 percent of traditional Medicare beneficiaries switched to Medicare Advantage, and a similar percentage of Medicare Advantage enrollees switched to traditional Medicare. These results suggest that initial coverage decisions have long-lasting effects.

Managing chronic illness: physician practices increased the use of care management and medical home processes.

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.

Patient-centered medical homes in Louisiana had minimal impact on Medicaid population's use of acute care and costs.

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Trends in New South Wales infant hospital readmission rates in the first year of life: a population-based study.

OBJECTIVE: To examine the trends in hospital readmissions in the first year of life and identify whether changes in maternal and infant risk factors explain any changes. DESIGN: Population-based study using de-identified linked health data. PARTICIPANTS: All 788 798 live-born infants delivered in New South Wales from 1 January 2001 to 31 December 2009 with a linked birth and hospital record. MAIN OUTCOME MEASURES: The number of infants readmitted to hospital at least once after discharge home from the birth admission to 1 year of age, per 100 live births each year, and changes in maternal and infant risk factors assessed by logistic regression. RESULTS: The number of infants readmitted to hospital up to age 1 year decreased by 10.5% (average annual reduction, 1.8%; 95% CI, - 1.7% to - 0.01%, P = 0.001), from 18.4 per 100 births in 2001 to 16.5 in 2009. Fifty-five per cent of this decrease could be explained by changes in factors that are associated with likelihood of hospitalisation; length of stay during the birth admission, maternal age and maternal smoking. The rate of readmissions for jaundice and feeding difficulties increased significantly over the study period, while readmissions for infections decreased. CONCLUSIONS: There has been a decrease in the rate of infants readmitted to hospital in the first year of life, which can be partly explained by increasing maternal age, decreasing maternal smoking and a shift to shorter length of hospital stay at birth. Improved maternal and neonatal care in hospital and increased postnatal support at home may have contributed to reduced risk of readmission.

["Hic gaudet mors succurere vitae", autopsy findings of the Mainz Institute of Pathology 1971-2010. An analysis on the occasion of the 100 year jubilee]. / "Hic gaudet mors succurere vitae", Sektionsbefunde der Mainzer Pathologie 1971-2010. Eine Analyse aus Anlass des 100-jährigen Jubiläums.

In the past numerous analyses have studied several aspects of autopsies in particular with regard to the decline of frequency; however, long-term studies spanning more than one decade have rarely been published, especially in recent years. On the occasion of the 100 year jubilee the archive data of the Institute of Pathology of the University of Mainz were analyzed for autopsies performed between 1971 and 2010. In this cohort, we focused on patients over 14 years old (n = 14,724) who died in the University hospital. We compared the number of autopsies with the total number of deceased patients and, in addition, studied several epidemiological aspects with special relevance for the cause of death (COD). In 1973 the peak autopsy frequency was reached with a value of 73.4 % followed by a decrease to 49.1 % in 1980. In the following decade a relatively steady state was achieved (frequency 53.3 % in 1985, and 43.2 % in 1990), followed by a remarkable decline after the 1990s (1997: 26.4 %, 1998: 15.9 % and 2010: 5.6 %). The mean overall age increased during the observation period (59.1 years in 1971 and 67.5 years in 2008). Among the COD groups cardiovascular diseases were predominantly recorded (between 35 % in the 1970s and 39 % in 1995-2010), followed by infectious diseases (between 20 and 25 %). Malignancies represented the third most common COD group with an increase in frequency from approximately 10.5 % in the 1970s to 17 % observed in the last decade. Among the single specific CODs, pulmonary embolism was most often encountered in the 1970s (about 11.5 %), while in the following decades myocardial infarction predominated (up to 15.8 % between 1995 and 2010). In the overall period, lung cancer was the single most common malignancy of the CODs (between 2.5 and 3.9 %). These data confirmed previous studies showing that in Germany the autopsy frequency began to decline remarkably in the 1990s. Besides general aspects, the specific local causes for these phenomena are discussed.