Application of DMAIC Cycle and Modeling as Tools for Health Technology Assessment in a University Hospital

Background. The Health Technology Assessment (HTA) is used to evaluate health services, manage healthcare processes more efficiently, and compare medical technologies. The aim of this paper is to carry out an HTA study that compares two pharmacological therapies and provides the clinicians with two models to predict the length of hospital stay (LOS) of patients undergoing oral cavity cancer surgery on the bone tissue. Methods. The six Sigma method was used as a tool of HTA; it is a technique of quality management and process improvement that combines the use of statistics with a five-step procedure: “Define, Measure, Analyze, Improve, Control” referred to in the acronym DMAIC. Subsequently, multiple linear regression has been used to create two models. Two groups of patients were analyzed: 45 were treated with ceftriaxone while 48 were treated with the combination of cefazolin and clindamycin. Results. A reduction of the overall mean LOS of patients undergoing oral cavity cancer surgery on bone was observed of 40.9% in the group treated with ceftriaxone. Its reduction was observed in all the variables of the ceftriaxone group. The best results are obtained in younger patients (−54.1%) and in patients with low oral hygiene (−52.4%) treated. The regression results showed that the best LOS predictors for cefazolin/clindamycin are ASA score and flap while for ceftriaxone, in addition to these two, oral hygiene and lymphadenectomy are the best predictors. In addition, the adjusted R squared showed that the variables considered explain most of the variance of LOS. Conclusion. SS methodology, used as an HTA tool, allowed us to understand the performance of the antibiotics and provided variables that mostly influence postoperative LOS. The obtained models can improve the outcome of patients, reducing the postoperative LOS and the relative costs, consequently increasing patient safety, and improving the quality of care provided

A Health Technology Assessment in Maxillofacial Cancer Surgery by Using the Six Sigma Methodology

Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples “Federico II”, two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC (Define, Measure, Analyse, Improve, Control) cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly (p-value < 0.05) in both groups. Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research

Contrast-Enhanced Magnetic Resonance Cholangiography: Practical Tips and Clinical Indications for Biliary Disease Management

Since its introduction, MRCP has been improved over the years due to the introduction of several technical advances and innovations. It consists of a noninvasive method for biliary tree representation, based on heavily T2-weighted images. Conventionally, its protocol includes two-dimensional single-shot fast spin-echo images, acquired with thin sections or with multiple thick slabs. In recent years, three-dimensional T2-weighted fast-recovery fast spin-echo images have been added to the conventional protocol, increasing the possibility of biliary anatomy demonstration and leading to a significant benefit over conventional 2D imaging. A significant innovation has been reached with the introduction of hepatobiliary contrasts, represented by gadoxetic acid and gadobenate dimeglumine: they are excreted into the bile canaliculi, allowing the opacification of the biliary tree. Recently, 3D interpolated T1-weighted spoiled gradient echo images have been proposed for the evaluation of the biliary tree, obtaining images after hepatobiliary contrast agent administration. Thus, the acquisition of these excretory phases improves the diagnostic capability of conventional MRCP—based on T2 acquisitions. In this paper, technical features of contrast-enhanced magnetic resonance cholangiography are briefly discussed; main diagnostic tips of hepatobiliary phase are showed, emphasizing the benefit of enhanced cholangiography in comparison with conventional MRCP

CO on supported Cu nanoclusters: Coverage and finite size contributions to the formation of carbide via the boudouard process

The interaction of carbon monoxide with an ordered array of copper nanoclusters was investigated under ultrahigh vacuum conditions by means of in situ X-ray photoelectron spectroscopy in combination with density functional theory calculations. The Cu clusters were supported on an alumina template grown on the Ni3Al(111) termination. Adsorption and dissociation of carbon monoxide occur at the copper clusters, yielding accumulation of carbidic carbon at the metal particles through the Boudouard process. The involved mechanisms are investigated at the atomic level, unveiling the effects of cluster finite size, reconstruction, support, and of local CO coverage. It is found that the high coverage of CO at the cluster surface, which considerably exceeds that achievable on single crystal surfaces, facilitates the metal restructuring and the reaction, yielding carbon incorporation into the bulk of the particles

Cultural and socio-economic impacts of Mediterranean marine protected areas

Marine protected areas (MPAs) may be important for protecting the marine environment, but they may also have substantial socio-cultural impacts about which very little is currently known, or acknowledged. In the Mediterranean, few data are available on the socio-economic consequences of MPAs. The present study reviews the existing data on MPAs in Spain, France, Italy and Greece. A general increase in tourist activities in Mediterranean MPAs is evident, as are increases in the abundances of larger fish species, although there are no data indicating yields for fisheries increase adjacent to MPAs. A large increase in the number of divers and vessels using MPAs has already had impacts on natural benthic communities as a result of diver damage, mooring and the feeding of large fish by divers. Emphasis has been given in only a few MPAs to promoting public awareness of these impacts. Although the conservation of nature should be considered the fundamental objective of MPAs, neglecting their social, cultural and economic impacts has at times led to poor local consensus, if not hostility. We believe that planning and managing MPAs should be conducted on a multidisciplinary basis. Nonetheless, no single model can be considered valid for the whole Mediterranean. The very variable characteristics of coastal areas, from those of small uninhabited islands to those of cities, require different weightings to be assigned for each factor in order to achieve a durable equilibrium and realize the original objectives of each MPA. Only with such flexibility of management will it be possible to reach a greater understanding of the MPA system and create a lasting consensus in favour of conservation, a consensus which would mean an overwhelming majority of people actively avoiding damaging nature and preventing others from doing so.This paper was realized with funds from the EU CEC DGXII–MAST III contract number: MAS3-ct97–0155

Stopping Smoking Reduces Mortality in Low-Dose Computed Tomography Screening Participants

Abstract Introduction The National Lung Screening Trial has achieved a 7% reduction in total mortality with low-dose computed tomography (LDCT) screening as compared with in the chest radiography arm. Other randomized trials are under way, comparing LDCT screening with no intervention. None of these studies was designed to investigate the impact of smoking habits on screening outcome. In the present study, we tested the effect of stopping smoking on the overall mortality of participants undergoing repeated LDCT screening for many years. Methods Between 2000 and 2010, 3381 smokers aged 50 years or older were enrolled in two LDCT screening programs. On the basis of the last follow-up information, subjects were divided into two groups: current smokers throughout the screening period and former smokers. Results With a median follow-up time of 9.7 years and a total of 32,857 person-years (PYs) of follow-up, a total of 151 deaths were observed in the group of 1797 current smokers (17,846 PYs) versus 109 among 1584 former smokers (15,011 PYs), corresponding to mortality rates of 8.46 and 7.26 for every 1000 PYs, respectively. Compared with current smokers, former smokers had an adjusted mortality hazard ratio of 0.61 (95% confidence interval: 0.44–0.83), with a 39% reduction in mortality. A similar reduction in mortality was observed in the subset of 712 late quitters, with a hazard ratio of 0.65 (95% confidence interval: 0.44–0.96). Conclusions Stopping smoking significantly reduces the overall mortality of smokers enrolled in LDCT screening programs. The beneficial effect of stopping smoking on total mortality appears to be threefold to fivefold greater than the one achieved by earlier detection in the National Lung Screening Trial

Do Autistic Traits Correlate with Post-Traumatic Stress and Mood Spectrum Symptoms among Workers Complaining of Occupational Stress?

The adult autism subthreshold spectrum model appears to be a useful tool for detecting possible vulnerability factors in order to develop mental disorders in the contest of work-related stress. The aim of the present study is to analyze the relationship between autism, mood, and post-traumatic spectrum in a cohort of subjects complaining of work-related stress before the COVID-19 pandemic. The authors carried out a retrospective investigation of both medical records and self-assessment tools of a sample of subjects evaluated at the Occupational Health Department of a University hospital in central Italy. Data showed significant correlations between the AdAS spectrum, TALS-SR, and MOODS total and domain scores. A multiple linear regression evidenced that both the AdAS spectrum and TAL-SR significantly predict the MOODS scores. In particular, mediation analysis showed both a direct and indirect, mediated by TALS-SR, effect of the AdAS Spectrum on the MOODS-SR. These results corroborate the role of autistic traits in influencing the traumatic impact of work-related stress and the development of mood spectrum symptoms

Migration Restrictions and Criminal Behavior: Evidence from a Natural Experiment *

Abstract We estimate the causal effect of immigrants&apos; legal status on criminal behavior exploiting exogenous variation in migration restrictions across nationalities driven by the last round of the European Union (EU) enlargement. Unique individual-level data on a collective clemency bill enacted in Italy five months before the enlargement allow us to compare the post-release criminal record of inmates from new EU member countries with a control group of pardoned inmates from candidate EU member countries. Differences in differences in the probability of rearrest between the two groups before and after the enlargement show that obtaining legal status lowers the recidivism of economically motivated offenders, but only in areas that provide relatively better labor market opportunities to legal immigrants. We provide a search-theoretic model of criminal behavior that is consistent with these results