Background: Artificial intelligence-based technology systems offer an alternative solution for diabetic retinopathy (DR) screening compared with standard, in-office dilated eye examinations. We performed a cost-effectiveness analysis of Automated Retinal Image Analysis System (ARIAS)-based DR screening in a primary care medicine clinic that serves a low-income patient population. Methods: A model-based, cost-effectiveness analysis of two DR screening systems was created utilizing data from a recent study comparing adherence rates to follow-up eye care among adults ages 18 or older with a clinical diagnosis of diabetes. In the study, the patients were prescreened with an ARIAS-based, nonmydriatic (undilated), point-of-care tool in the primary care setting and were compared with patients with diabetes who were referred for dilated retinal screening without prescreening, as is the current standard of care. Using a Markov model with microsimulation resulting in a total of 600 000 simulated patient experiences, we calculated the incremental cost-utility ratio (ICUR) of the two screening approaches, with regard to five-year cost-effectiveness of DR screening and treatment of vision-threatening DR. Results: At five years, ARIAS-based screening showed similar utility as the standard of care screening systems. However, ARIAS reduced costs by 23.3%, with an ICUR of $258 721.81 comparing the current practice to ARIAS. Conclusions: Primary care-based ARIAS DR screening is cost-effective when compared with standard of care screening methods.

Background Cancer is emerging as a major cause of childhood mortality in low-income and middle-income countries. In Mexico, cancer is the number one cause of death in children aged 5–14. Until recently, many children with cancer from Baja California, Mexico went untreated. We reasoned that an initiative inspired by the St. Jude Children’s Research Hospital (SJCRH) “twinning” model could successfully be applied to the San Diego–Tijuana border region. In 2008, a twinning project was initiated by Rady Children’s Hospital, SJCRH and the General Hospital Tijuana (GHT). Our aim was to establish a pediatric oncology unit in a culturally sensitive manner, adapted to the local health care system. Procedure An initial assessment revealed that despite existence of basic hospital infrastructure at the GHT, the essential elements of a pediatric cancer unit were lacking, including dedicated space, trained staff, and uniform treatment. A 5-year action plan was designed to offer training, support the staff financially, and improve the infrastructure. Results After seven years, accomplishments include the opening of a new inpatient unit with updated technology, fully-trained staff and a dedicated, interdisciplinary team. Over 700 children have benefited from accurate diagnosis and treatment. Conclusions Initiatives that implement long-term partnerships between institutions along the Mexican-North American border can be highly effective in establishing successful pediatric cancer control programs. The geographic proximity facilitated accelerated training and close monitoring of project development. Similar initiatives across other disciplines may benefit additional patients and synergize with pediatric oncology programs to reduce health disparities in underserved areas.

In 2007, the 5-year survival rate for children with acute leukemia in Baja California, Mexico was estimated at 10% (vs. 88% in the United States). In response, stakeholders at St. Jude Children’s Research Hospital, Rady Children’s Hospital San Diego, and the Hospital General de Tijuana (HGT) implemented a transcultural partnership to establish a pediatric oncology program. The aim was to improve clinical outcomes and overall survival for children in Baja California. An initial needs assessment evaluation was performed and a culturally sensitive, comprehensive, 5-year plan was designed and implemented. After six years, healthcare system accomplishments include the establishment of a fully functional pediatric oncology unit with 60 new healthcare providers (vs. five in 2007). Patient outcome improvements include a rise in 5-year survival for leukemia from 10 to 43%, a rise in new cases diagnosed per year from 21 to 70, a reduction in the treatment abandonment rate from 10% to 2%, and a 45% decrease in the infection rate. More than 600 patients have benefited from this program. Knowledge sharing has taken place between teams at the HGT and Rady Children’s Hospital San Diego. Further, one of the most significant outcomes is that the HGT has transitioned into a regional referral center and now mentors other hospitals in Mexico. Our results show that collaborative initiatives that implement long-term partnerships along the United States–Mexico border can effectively build local capacity and reduce the survival gap between children with cancer in the two nations. Long-term collaborative partnerships should be encouraged across other disciplines in medicine to further reduce health disparities across the United States–Mexico border.

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Transforming the US health system, or any other health system, will be neither easy nor quick. Applying complexity concepts to health reform efforts, however, will facilitate long-term change in all levels, leading to health systems that are more effective, efficient, and equitable.

Costing data for intensive care admissions is important, not only for unit funding, but also for cost outcome analysis of new therapies. This paper presents an intensive care episode costing methodology using the example of a cost-benefit analysis of mask CPAP for severe cardiogenic pulmonary oedema (CPO). This analysis examines the intervention of admitling all patients with severe CPO to the intensive care unit for mask CPAp, compared with the previous practice of admitting only patients failing conventional non-CPAP treatment and requiring mechanical ventilation. The episode costs were determined from a prospective study which showed mask CPAP reduced the need for mechanical ventilation from 35% to 0%. The mean cost of a mask CPAP episode was $1,156, with a mean stay of 1.2 days, compared with ventilated patients, $5,055 and 4.2 days. The major contributors to cost in both groups were nursing and medical salaries, and hospital overheads. The cost of previous estimated yearly caseload of 35 ventilated patients ($176,925) was greater than the cost associated with an increased caseload of 100 mask CPAP patients ($1J5,600). We conclude that, despite an increase in admissions, mask CPAP for severe CPO is cost-effective.

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Abstract Objective This study aims to discuss clinical characteristics of burn patients who developed elevated intraocular pressure (IOP). We propose management strategies to prevent orbital compartment syndrome before invasive treatment is required. Methods A retrospective review of 47 burn patients at the University of California San Diego (UCSD), Burn Intensive Care Unit (ICU; major regional burn center for San Diego county), was analyzed for demographics, fluid resuscitation volumes, and physical exam findings. Patients requiring topical treatment for high-IOP, defined as ≥30 mm Hg in either or both eyes, were compared with those who did not require treatment, using the t-test and Fisher's exact test. Linear regression tested for an association between peak IOP and fluid volume. Logistic regression evaluated the association between total fluid and treatment of high IOP, while adjusting for other characteristics. Results Six of 47 patients required IOP-lowering treatment. Of the patients requiring treatment, one drop of dorzolamide/timolol in both eyes twice daily was the most common treatment recommendation. Presence of periocular burns was a significant risk factor in patients who required treatment for high IOP. No patients developed orbital compartment syndrome or required surgical intervention to lower IOP. The mean total fluid volume delivered in the first 24 hours was 0.8 times the level prescribed by fluid resuscitation guidelines. Conclusion By treating early clinical signs and properly managing fluid resuscitation, development of orbital compartment syndrome in burn patients can be avoided.