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To examine the effect of cost-sharing on the use of asthma medications in asthmatic children. According to asthma guidelines, children with asthma may require treatment with multiple medications, including controllers and relievers, to achieve optimal control. Although families may be enrolled in drug benefit plans, impediments to access persist in the form of cost-sharing. Design: Population-based retrospective cohort study of children by analysis of administrative medication insurance claims data.

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Background: In patients with ST-segment-elevation myocardial infarction (MI), timely treatment with primary percutaneous coronary intervention (PPCI) with door-to-balloon (D2B) time <90 minutes is recommended by the current guidelines. Recent study showed continuous association between shortening D2B time to < 60 minutes and reducing mortality risk.D2B time was maintained below the international target of <90 minutes for patients directly arriving to Heart Hospital emergency department (ED) for the last three years. Aim: Our aim is to reduce D2B time for PPCI to reach the new target of < 60 minutes by the end of August 2019. Method: We started our improvement project by understanding the current process and identifying theareas were delay occurred using Safety I concept. Several reasons of delays were identified: Delay in receiving and preparing the patient in ED Several handovers during patient transfer to Cath Lab. Delay in staff arrival to Heart Hospital during the busy traffic after 3:00 pm Back to back procedures during the busy working hours (7:00 am to 3:00 pm) IHI model for improvement was used to test the effectiveness of the suggested changes.Change Concepts: September 2018 - well trained intensive PPCI nurse was assigned daily during the evening and the night shift to manage the patient from ED arrival to the Cath Lab procedure room and from Cath lab following procedure to the destination unit. January 2019 - The role of PPCI nurse extended to all shifts (24 hours) January 2019 - In house Cath lab team (from 3:00 pm to 10 pm) to overcome travel delay during peak traffic hours. August 2019 - Cardiology fellow from the Cath Lab team receives the patient from arrival at ED door. This reduced the time patient spent in the ED. In May 2019 we tried to apply the concept of Safety II: Weekly data for the shortest D2B time compared to the average D2B was posted in the Cath lab and circulated to all staff with the names of the team members involved. This approach allowed us to learn from good experience and share that experience. It also empowered the team to do better in the future cases. Reasons for achieving weekly shortest D2B were collected and analyzed. It has been found that interventionist had made some corrective actions to avoid delay: Many interventionists accept the case based on the ambulance ECG and activate the Cath lab from the field before patient arrived at the ED.o To avoid delay due to difficulty in registration, some interventionists start the procedure without a full registration. Some on call interventionist stayed in the hospital. Results: We achieved our target of reducing D2B time to < 60 minutes before the end of 2019. Conclusion: Door to balloon time for primary percutaneous coronary intervention was successfully reduced to the new <60 minutes target by Integrating of both safety I and Safety II concepts.

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