Purpose: To estimate travel distance and time for US hemodialysis patients and to compare travel of rural versus urban patients.Methods: Dialysis patient residences were estimated from ZIP code-level patient counts as of February 2011 allocated within the ZIP code proportional to census tract-level population, obtained from the 2010 US Census. Dialysis facility addresses were obtained from Medicare public-use files. Patients were assigned to an "original" and "replacement" facility, assuming patients used the facility closest to home and would select the next closest facility as a replacement, if a replacement facility was required. Driving distances and times were calculated between patient residences and facility locations using GIS software. Findings:The mean one-way driving distance to the original facility was 7.9 miles; for rural patients average distances were 2.5 times farther than for urban patients (15.9 vs 6.2 miles). Mean driving distance to a replacement facility was 10.6 miles, with rural patients traveling on average 4 times farther than urban patients to a replacement facility (28.8 vs 6.8 miles). Conclusion:Rural patients travel much longer distances for dialysis than urban patients. Accessing alternative facilities, if required, would greatly increase rural patient travel, while having little impact on urban patients. Increased travel could have clinical implications as longer travel is associated with increased mortality and decreased quality of life.
Background: The costs of transporting end-stage renal disease (ESRD) patients to dialysis centers are high and growing rapidly. Research has suggested that substantial cost savings could be achieved if medically appropriate transport was made available and covered by Medicare. Objectives: To estimate US dialysis transportation costs from a purchaser’s perspective, and to estimate cost savings that could be achieved if less expensive means of transport were utilized. Methods: Costs were estimated using an actuarial model. Travel distance estimates were calculated using GIS software from patient ZIP codes and dialysis facility addresses. Cost and utilization estimates were derived from fee schedules, government reports, transportation websites and peer-reviewed literature. Results: The estimated annual cost of dialysis transportation in the United States is $3.0 billion, half of which is for ambulances. Most other costs are due to transport via ambulettes, wheelchair vans and taxis. Approximately 5% of costs incurred are for private vehicle or public transportation use. If ambulance use dropped to 1% of trips from the current 5%, costs could be reduced by one-third. Conclusions: Decision-makers should consider policies to reduce ambulance use, while providing appropriate levels of care.
There is continuing uncertainty about the effects of various degrees of systemic arterial hypertension on myocardial ischemia. In 46 open-chest anesthetized dogs, intramural carbon dioxide tension (PmCO2) was measured directly with a mass spectrometer during repetitive 10-min coronary artery occlusions separated by 45-min periods of reflow. During each occlusion, transmural regional myocardial blood flow (RMBF) in the ischemic area was quantitated with the injection of radioactive microspheres (7-10 micrometers diam). In all dogs the increase in PmCO2 from before to 10 min after the first occlusion (delta PmCO2) exceeded that during subsequent occlusions. In those dogs in which systemic arterial hypertension was not produced (controls), delta PmCO2 during the third occlusion was similar to that during the second occlusion. When phenylephrine was administered during the third occlusion to increase systemic arterial pressure mildly (diastolic pressure 95-115 mmHg), RMBF to the ischemic myocardium was unchanged, and the severity of myocardial ischemia was reduced, as reflected by a fall in delta PmCO2. When diastolic pressure was elevated moderately (116-140 mmHg), RMBF was augmented, but the extent of myocardial ischemia was neither diminished nor worsened. In contrast, when diastolic pressure was increased markedly (greater than 140 mmHg), myocardial ischemic injury was intensified (as reflected by an increase in delta PmCO2) even though RMBF rose significantly. Thus, in the dog with acute coronary artery occlusion, an increase of systemic arterial pressure exerts an influence on the severity of myocardial ischemic injury that is related directly to the magnitude of systemic arterial hypertension: a mild increase of pressure reduces ischemic injury, a moderate increase exerts no consistent effect on ischemia, and a marked increase worsens ischemic injury.
While electronic health records (EHRs) have been shown to be effective in improving patient care in low-resource settings, there are still barriers to implementing them, including adaptability, usability, and sustainability. Taking a user-centered design process we developed the Hikma Health EHR for low resourced clinics caring for displaced populations. This EHR was built using React Native and Typescript that sync to a Python backend repository which is deployed on Google Cloud SQL. To date the Hikma Health EHR has been deployed for 26,000 patients. The positive impacts of the system reported by clinician users are 3-fold: (1) improved continuity of care; (2) improved visualization of clinical data; and (3) improved efficiency, resulting in a higher volume of patients being treated. While further development is needed, our open-source model will allow any organization to modify this system to meet their clinical and administrative needs.
The purpose was to determine the biochemical and hemodynamic adaptations of the myocardium to chronic tachycardia. Cardiac pacemakers were implanted in Yorkshire pigs and set at a rate of 180 beats/min for a period of 35-42 days. Animals were then anesthetized with pentobarbital sodium. Myocardial blood flow and hemodynamics were determined at three different heart rates (i.e., 120, 180, and 220 beats/min). Tissue samples were then taken for microsphere and biochemical analyses. Chronically paced hearts maintained better cardiac function and had consistently higher left ventricular blood flow with a higher endocardial-to-epicardial ratio. The activities of citrate synthase and 3-hydroxyacyl-CoA dehydrogenase were 23 and 45% greater in the paced hearts, respectively. The sarcoplasmic reticulum adenosinetriphosphatase activity was 55% greater in the paced hearts, whereas the myosin adenosinetriphosphatase was the same as in the control hearts. Polyacrylamide gels of the ventricular myosin isoforms showed only the V3 type to be present in both the control and paced hearts. These findings show that the heart of a large mammal adapts to chronic tachycardia (i.e., 180 beats/min) by elevating the aerobic and calcium-sequestering capacities without altering its myosin type.
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