Cost-effectiveness of Different Advanced Life Support Providers for Victims of Out-of-hospital Cardiac Arrests

Background/purposeThe survival rate of out-of-hospital cardiac arrest (OHCA) is only about 1.4% in Taiwan. The best configuration to achieve optimal outcomes in OHCA is still uncertain for many communities. The purpose of this study was to investigate the cost-effectiveness of two models of providing advanced life support (ALS) services, emergency medical technicians (EMTs) vs. emergency physicians (EPs), in a two-tiered emergency medical services (EMS) system.MethodsThis was a prospective, observational, multicenter study comparing ALS provided by EMTs vs. EPs for the management of victims of OHCA. The study population consisted of patients experiencing OHCA of non-traumatic origin in Taipei city, Taiwan, between November 1999 and December 2000, for whom ALS was activated. We performed a cost-effectiveness analysis to determine the economic attractiveness of these two ALS provider programs. The outcome measurements were aggregate costs, survival and incremental cost per life saved. Sensitivity analyses were performed on all variables.ResultsThe expected total cost per OHCA patient was US$2248.19 and US$832.07 for the EMT and EP programs, respectively. The overall survival rate was 4.4%. The survival rate was 9.3% for the EMT program and 2.6% for the EP program. The incremental cost-effectiveness ratio (ICER) of EMTs vs. EPs was US$21,136 per life saved. The ICER was sensitive to hospital admission cost changes and the probability of survival to discharge in patients admitted to hospital in the EMT program. The increased survival rate of OHCA patients in the EMT program may be attributable to the services of the hospital and/or the EMT program.ConclusionThe use of EMTs as ALS care providers for OHCA patients in the two-tiered EMS system resulted in a reasonable cost-effectiveness ratio. EMTs could be considered as the second tier of EMS systems in urban areas in Taiwan

以超音波篩檢臨床上懷疑壞死性筋膜炎的病人

Objective: To determine the accuracy of ultrasonography for the diagnosis of necrotizing fasciitis. Methods: This study was a prospective observational review of patients with clinically-suspected necrotizing fasciitis presenting at the emergency department of an urban (Taipei) medical center between October 1996 and May 1998. All patients underwent ultrasonographical examination, the ultrasonographical diagnosis of necrotizing fasciitis being based upon the criterion of a diffuse thickening of the subcutaneous tissue accompanied by a layer of fluid accumulation more than four millimeters in depth along the deep fascial layer when compared with the contralateral position on the corresponding normal limb. The final diagnosis of necrotizing fasciitis was determined upon pathological findings for patients who underwent fasciotomy or biopsy results for patients managed non-operatively. Results: Data were collected for 62 patients, of whom 17 (27.4%) were considered to suffer from necrotizing fasciitis. Ultrasonography revealed a sensitivity of 88.2 %, a specificity of 93.3%, a positive predictive value of 83.3%, a negative predictive value of 95.4%, and an accuracy of 91. 9% as regards the diagnosis of necrotizing fasciitis. Conclusions: Ultrasonography can provide accurate information for emergency physicians for the diagnosis of necrotizing fasciitis

Association between Particulate Matter and the Incidence of Out-of-Hospital Cardiac Arrest

背景 心因性猝死是已開發國家民眾之重要死因。在過去的研究中顯示，心因性猝死的發生會隨著晝夜、星期、季節的不同而產生週期性的變動。許多動物及人體研究的結果，提供了空氣污染的暴露和心血管疾病之相關致病機轉。到院前心跳停止是指在醫院外發生的心因性猝死，此研究在探討空氣懸浮微粒與到院前心跳停止病患發生率之相關性。 材料與方法 所有在2003年9月到2007年12月間，登錄在台北市緊急醫療網的成人到院前心跳停止病患均收錄在本研究中，排除條件為創傷、在現場沒有進行急救以及以事先聲明不要進行急救的病患。氣象及空氣污染指標包括一氧化碳、二氧化硫、氮氧化物、臭氧、空氣懸浮微粒(PM2.5和PM10)及氣溫等資料，是經由台灣環保署所取得。對於到院前心跳停止病患及空氣污染資料，將會進行描述性統計和分析。在時間序列分析中，將會採用卜瓦松迴歸模型(Poisson regression model)及廣義加法模型(generalized additive mode)，對於每日空氣污染濃度及每日的到院前心跳停止病患數，進行相關分析。在個案交叉(case-crossover)分析中，會採取每日時間及每週星期的配對來選取對照組，進而探討空氣污染濃度和到院前心跳停止的發生其相關性。在相關性分析中亦會進行敏感度分析和效應修正(effect modification)的探討。 結果 在研究期間共有6341個符合條件的到院前心跳停止病患，其平均年齡為71.7歲，男性多於女性。每日上午6點到10點以及下午5點到8點是發生到院前心跳停止的尖峰期，冬季的個案發生率明顯增加，在星期一、五、六和日的個案發生率也是比較高。空氣中一氧化碳和氮氧化物的濃度存在高度相關，兩種懸浮微粒(PM2.5和PM10)的濃度也是彼此相關。 時間序列分析的結果顯示，懸浮微粒濃度的上升和到院前心跳停止發生率呈現正相關的趨勢。在個案交叉(case-crossover)分析中，24小時前的懸浮微粒(PM2.5和PM10) 24小時平均濃度，和到院前心跳停止的發生率，有統計上明顯的正相關。PM10之濃度每增加一個四分位間距(interquartile range)或29.01 µg/m3，發生到院前心跳停止的勝算比(odds ratio)為1.054，其95%信賴區間為1.017至1.093。PM2.5之濃度每增加一個四分位間距(interquartile range)或19.21 ug/m3，發生到院前心跳停止的勝算比(odds ratio)為1.060，其95%信賴區間為1.022至1.099。這樣的相關性在男性以及年齡40到74歲的族群更加明顯。 研究限制 到院前心跳停止的病患不見得會真的暴露在空氣污染之中，病患的真實暴露和空氣污染測量站的數值之間可能存在偏差。在緊急醫療網資料庫中有限的個人資料，限制了時間序列分析的能力以及效應修正範圍上的探討。 結論 空氣懸浮微粒和到院前心跳停止的發生是存在正相關的連結，空氣污染的防制可能可以成為減少心血管疾病死亡的預防措施。 關鍵字：懸浮微粒，空氣污染，心因性猝死，心跳停止，心血管疾病Background Sudden cardiac death is the leading cause of death in developed countries. Circadian, weekly, and seasonal variations in the incidence of sudden cardiac death have been observed. Numerous animal and human studies provide biological evidence linking air pollution exposure and cardiovascular disease. Sudden cardiac death occurring outside hospital is usually referred to as out-of-hospital cardiac arrest (OHCA). This study was conducted to investigate the association between particulate matter (PM) and the incidence of OHCA. Material and Methods All adult OHCA patients that activated the emergency medical service system in Taipei city from September 2003 through December 2007 were included in the study. Patients with traumatic injuries, and patients for whom resuscitation was not attempted by emergency medical service personnel due to terminal illness or an existing do-not-attempt-resuscitate order were excluded. The data of climate and air pollution measurements, including carbon monoxide (CO), sulfur dioxide (SO2), nitrogen oxide (NO), nitrogen dioxide (NO2), ozone (O3), particulate matters (PM2.5 and PM10), and temperature were obtained from the Taiwan Environmental Protection Administration. Descriptive analyses of the study targets and air pollution data were performed. In the time-series analysis, Poisson regression models and generalized additive models were applied to analyze the association between daily-averaged air pollutant levels and daily OHCA patient numbers. The case-crossover design with matching by hour-of-day and day-of-week was used to explore the association between the incidence of OHCA and air pollution levels. Sensitivity analysis and investigations on effect modification were performed. Results There were 6341 cases of OHCA during the study period. The mean age was 71.7 years, and the study targets included more men than women. Circadian variation was observed, with a maximum occurrence rate between 6 and 10 AM and a secondary evening peak between 5 and 8 PM. There were significantly more OHCA patients during winter. Compared to other weekdays, there were significantly more OHCA patients on Monday, Friday, Saturday, and Sunday. There was high correlation between CO, NO, NO2 and NOx levels. PM2.5 was also highly correlated with PM10. In the time-series analysis, positive trends indicated that increasing PM10 and PM2.5 levels were associated with increasing incidence of OHCA. However, in the case-crossover analysis, the 24-hour mean PM10 and PM2.5 levels with 24-hour lag were significantly associated with the incidence of OHCA. For an increase of one interquartile range (29.01 µg/m3 ) in PM10, the odds ratio estimate for OHCA was 1.054 (95% confidence interval: 1.017- 1.093). For an increase of one interquartile range (19.21 µg/m3) in PM2.5, the odds ratio estimate for OHCA was 1.060 (95% confidence interval: 1.022- 1.099). These associations were stronger in males and in the 40- 74-year group. Limitations There is no assurance that OHCA patients were indeed exposed to air pollution. Discrepancies between ambient and actual personal exposures may exist. Limited personal information in the database restricted the power of time-series analysis and the extent of exploring effect modification. Conclusion Particulate matter is positively associated with the incidence of OHCA. Controlling air pollution may be a preventable means to decrease cardiovascular mortality. Key words: particulate matter, air pollution, sudden cardiac death, cardiac arrest, cardiovascular disease

治療急性腎盂炎的成本效果分析

At least 250,000 episodes of acute uncomplicated pyelonephritis are treated annually in the Emergency Department (ED). Trimethoprim- sulfamethoxazole (TMP-SMX) and norfloxacin have both been used as treatments for acute uncomplicated pyelonephritis. Objective: To investigate the cost-effectiveness of two outpatient treatment strategies, TMP-SMX and norfloxacin, for acute uncomplicated pyelonephritis in adult women between the age of 18 and 65. Methods: Common principles of cost- effectiveness analysis were used for this evaluation. We developed a decision tree to estimate the costs and effectiveness of two different treatment strategies: TMP/SMX 160/800 mg twice per day for 10 days and norfloxacin 400 mg twice per day for 10 days. The time frame of the decision tree was eleven days. Outcomes were expressed in US dollars, quality-adjusted life -days (QALDs), and dollars per QALD. Sensitivity analyses were performed on most variables. Results: Given current costs and cure rates, norfloxacin is more effective and less costly than the alternative, TMP-SMX, for out-patient pyelonephritis. This strategy will save $195.85 per patient, resulting in an aggregate savings of more than 40 million dollars annually. Patients are expected to enjoy a better quality of life with an incremental 0.0601 QALD per patient, if they are treated with norfloxacin. These results are robust across a wide range of probabilities and costs. Conclusions: In this analysis, norfloxacin 400 mg twice a day for 10 days is a more cost-effective treatment for woman with acute uncomplicated pyelonephritis

你願花多少錢去避免一種新的危險性感染疾病

Background: The risk of developing nosocomial infectious diseases among medical personnel in the emergency department (ED) can result in tremendous psychologic stress. The objective of this study was to estimate the median amount of money ED personnel would be willing to pay for preventing nosocomial severe acute respiratory syndrome (SARS). Methods : A contingent valuation approach with close-ended format was used. During the study period from June 15, 2003 through June 30, 2003, a convenience sample of all medical personnel working in the ED of National Taiwan University Hospital was carried out. Participants were interviewed by a standard questionnaire and were asked to choose whether or not they would pay at a specified price to purchase a hypothetical SARS vaccine. A logistic regression model was created to evaluate the relationship between willingness-to- pay and the log of the price offered in the bid questions . The median and mean amounts of willingness-to-pay were calculated. Results: A total of 115 subjects were interviewed and most were nurses (68 .7 %). The median and mean amount subjects reported being willing to pay for a SARS vaccine was US $1762 and US$720, respectively. Subject responses were significantly related to the price of vaccination and their type of job. Conclusions: Medical personnel in the ED reported that they would be willing to pay substantial monetary amounts for preventing nosocomial SARS

Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial

BACKGROUND: Patients with partial adhesive small-bowel obstruction are usually managed conservatively, receiving intravenous hydration and nothing by mouth. Previous studies have suggested that this approach is associated with longer hospital stays and an increased risk of delayed surgery. We conducted a randomized controlled trial to see if combining standard conservative treatment with oral administration of a laxative, a digestant and a defoaming agent would reduce the frequency of subsequent surgical intervention and reduce the length of hospital stay. METHODS: We identified 144 consecutive patients admitted between February 2000 and July 2001 with adhesive partial small-bowel obstruction and randomly assigned 128 who met the inclusion criteria to either the control group (intravenous hydration, nasogastric-tube decompression and nothing by mouth) or the intervention group (intravenous hydration, nasogastric-tube decompression and oral therapy with magnesium oxide, Lactobacillus acidophilus and simethicone). The primary outcome measures were the number of patients whose obstruction was successfully treated without surgery and the length of hospital stay. We also monitored rates of complications and recurring obstructions. RESULTS: Of the 128 patients, 63 were in the control group and 65 in the intervention group; the mean ages were 54.4 (standard deviation [SD] 15.9) years and 53.9 (SD 16.3) years respectively. Most of the patients were male. More patients in the intervention group than in the control group had successful treatment without surgery (59 [91%] v. 48 [76%], p = 0.03; relative risk 1.19, 95% confidence interval 1.03–1.40). The mean hospital stay was significantly longer among patients in the control group than among those in the intervention group (4.2 [SD 2.7] v. 1.0 [SD 0.7] days, p < 0.001). The complication and recurrence rates did not differ significantly between the 2 groups. INTERPRETATION: Oral therapy with magnesium oxide, L. acidophilus and simethicone was effective in hastening the resolution of conservatively treated partial adhesive small-bowel obstruction and shortening the hospital stay