Community water fluoridation has long been recognized as an effective public health intervention in the prevention of dental caries. The recently documented secular decline in dental caries, however, presents for policy makers the challenge of appropriately allocating limited health care resources between a variety of health care programs. Appropriate economic assessment of these alternatives becomes critical for rational distribution of such resources. Cost‐benefit and cost‐effectiveness analyses are techniques that, when used correctly, can guide policy makers facing such decisions. This paper reviews and critiques the published literature assessing the cost effectiveness and cost benefit of community water fluoridation using criteria developed for economic evaluation. Eight papers met the criteria for inclusion in the present study. In general, the articles failed to incorporate the declining prevalence of dental caries into their analyses and to fully document costs associated with water fluoridation. Treatment savings from dental care averted secondary to water fluoridation were not appropriately incorporated into the cost‐effectiveness analyses, thereby overestimating the marginal cost associated with fluoridation. Specification of outcome measures to assess the consequences of water fluoridation failed to incorporate the dynamic nature of dental disease. Suggestions for improving the generalizability and usefulness of future cost‐benefit and cost‐effectiveness analyses are made.
BACKGROUND: It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS).
OBJECTIVE: To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder.
INTERVENTION: The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed.
PRIMARY OUTCOME AND MEASURES: The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate.
RESULTS: There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates.
CONCLUSION: Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.
Current knowledge of the uptake and metabolism of the major energy yielding and nitrogenous nutrients that are naturally available to ruminal bacteria is reviewed. The potential use of metabolic engineering to manipulate these metabolic pathways and improve nutrient utilization in ruminant animals is briefly discussed. Metabolic engineering is the use of recombinant DNA techniques to enhance microbial function by manipulating enzymatic, transport and regulatory functions of the cell. Examples of the use of metabolic engineering in industrial fermentation are also given.
ObjectivesWhen initiated in the Emergency Department (ED), medication for addiction treatment (MAT) with buprenorphine improves outcomes, increases engagement in addiction treatment and decreases the use of inpatient addiction treatment services. Unfortunately, initiating MAT in the ED is not yet standard practice. We assessed the impact of the addition of a multipart behavioral science-based intervention to increase opioid use disorder (OUD)-related treatments prescribed in the ED.MethodsOur ED initiated a campaign to help ED faculty obtain their DEA-X waiver required to prescribe buprenorphine. In parallel, we implemented 2 ED-initiated buprenorphine treatment pathways. We then conducted a two-stage qualitative process informed by behavioral science to identify key barriers to physician use of the MAT protocol. Using these insights, we developed 4 behavioral science-based interventions. To assess the impact of the interventions on the number of OUD-related treatments per day among patients meeting the inclusion criteria we compared the number of OUD-related treatments per day before versus after the interventions began using t tests. Then, in our primary model, we estimated the causal effect of the behavioral interventions using a regression discontinuity in time approach.ResultsAcross the entire year study period, there is an increase in OUD-related treatment after the interventions begin, driven by greater use of ambulatory referral orders. The unadjusted mean difference in any OUD treatments per day pre- versus post-intervention increased by 0.80 (95% confidence interval [CI]: 0.04, 1.56; P = 0.039) whereas the number of ambulatory referral orders placed increased by 0.82 (95% CI: 0.48,1.16; P < 0.001). Using the 120-day study window and an ordinary least squares regression discontinuity in time model, the 4-part intervention increased the number of patients receiving any opioid treatment in the ED by 1.6 additional treatments per day (95% CI: 0.04, 3.19; P = 0.045).ConclusionsTo support our protocol and increase the provision of ED-MAT, we implemented 1 patient-facing and 3 provider-facing interventions rooted in behavioral science principles. Our results show that this pack of behavioral science interventions increased the likelihood that ED providers offer MAT to patients with OUD.
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