Disparities in Utilization and Outcomes of Minimally Invasive Techniques for Gastric Cancer Surgery in the United States

Background This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States. Methods The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications. Results There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost. Conclusions In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

Multi-National Implementation

It is an extremely important feature of Grondona's system that, just as any country implementing it would do so independently on a scale appropriate to their economy, many different countries could establish a CRD without any need for coordination and without in any way hindering each other. On the contrary, as the number of CRDs increased, their collective stabilizing influence on commodity markets would increase proportionately. Moreover, the stabilizing influence on their mutual exchange rates would increase more than proportionately as the number of their mutual exchange rates grew. This contrasts sharply with the proposed international system of buffer stocks which could stabilize no more than a single currency and would become increasingly cumbersome as the number of participating countries increased.

Reforming Teacher and Leader Preparation to Improve Instruction and Schooling for Students With Disabilities: The CEEDAR Way

Effective preparation systems are critical for preparing teachers and school leaders who have the knowledge and skills to educate students with disabilities to achieve college and career ready standards. These systems must provide teachers and leaders with effective practice-based opportunities to learn about evidence-based and high-leverage practices in their initial preparation and throughout their careers. Creating such systems, however, depends on comprehensive systems change where aligned research-based policy and preparation/induction practices are implemented in higher education and k-12 schools. This article describes the ingredients of effective systems change, and how the CEEDAR Center TA approach is informed by implementation drivers, as articulated by the National Implementation Research Network. The outcomes achieved by the Center thus far are also articulated as are challenges encountered.

National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study

Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.

European Deposit Insurance Scheme(s) – Consequences for the EU’s Financial Stability

The aim of this paper is to evaluate the potential consequences that the shortcomings in harmonising the national deposit guarantee schemes may have on the financial stability of the European Union. The relevance of this subject is underlined both by the European Commission’s intention to revive the European Deposit Insurance Scheme project in 2021 and the recent signals from Germany that they are willing to support the initiative. The paper presents a review of the discussions on establishing a European Deposit Insurance Scheme, the reasons for the project’s failure and the consensus solution that took the form of the Deposit Guarantee Scheme Directive (DGSD). The limited scope of deposit guarantee scheme harmonisation under this directive is discussed in the context of the related EBA opinions pointing to different areas of potential improvements. Differences in national implementation are also reviewed in terms of their potential impact on financial stability. Apart from a careful literature review, statistical analysis of the available financial information characterizing the largest national deposit schemes of the euro is performed to quantify their progress towards the target level of the available financial means. The results prove that most national schemes are still far from reaching the 0.8% target level of readily available funds and that potentially desirable amendments to the DGSD may drag them even further away from reaching that target by 2024. The author concludes that from the perspective of financial stability, the EU should focus on establishing a single scheme at an international level that would complete the project of establishing a banking union. The results contribute to the ongoing discussion on the need to further integrate the national deposit guarantee schemes inside the EU.

An economic evaluation of reducing colorectal cancer surveillance intensity

Aim: Analyze the impact of national implementation of ‘low intensity’ post-treatment colorectal cancer surveillance compared with current practices. Materials & methods: Create a population-level Markov model to estimate impacts of expansion of low versus high intensity surveillance post-treatment on healthcare utilization, costs and caregiver time loss. Results: Shifting to low intensity colorectal cancer surveillance would reduce patient burden by 301,830 h per patient annually over 5 years. Cost reductions over 5 years were US$43.5 million for Medicare and US$4.2 million for Medicaid. Total societal cost savings equaled US$104.2 million. Conclusion: National implementation of low intensity post-treatment colorectal cancer surveillance has the potential to significantly reduce burden and costs on patients and their caregivers with no added risks to health.

The public health approach to suicide prevention in Ireland

This article provides an overview of the public health approach to suicide in Ireland. The authors provide detail on the current suicide prevention strategy in Ireland, Connecting for Life, which is a whole-of-government, systemic, multicomponent national strategy. As the strategy enters its final extended phase of implementation over the period 2020–2024, the public health elements of Connecting for Life are presented, including the population level and more targeted approaches. The findings of an interim review of the strategy are discussed, in addition to the local and national implementation structures which are in place to assist implementation and monitoring of the strategy.

Challenges to the implementation of in situ simulation at HEMS bases: a qualitative study of facilitators’ expectations and strategies

Introduction Facilitators play an essential role in simulation-based training on helicopter emergency medical services (HEMS) bases. There is scant literature about the barriers to the implementation of simulation training in HEMS. The purpose of this explorative interview study was to identify factors that the local facilitators anticipated would challenge the smooth implementation of the program, and their strategies to overcome these before the national implementation of in situ simulation-based training locally, and subsequently, one year after the programme was initiated, to identify the actual challenges they had indeed experienced, and their solutions to overcome these. Methods A qualitative study with semi-structured group interviews of facilitators was undertaken before and after one year of simulation-based training on all HEMS bases and one Search and Rescue base. Systematic text condensation was used to extract facilitators’ expectations and experiences. Results Facilitators identified 17 themes in the pre-study-year interviews. Pedagogical, motivational and logistical issues were amongst the dominant themes. Other key themes included management support, dedicated time for the facilitators and ongoing development of the facilitator. In the post-study-year interviews, the same themes were identified. Despite anxiety about the perceptions of, and enthusiasm for, simulation training amongst the HEMS crews, our facilitators describe increasing levels of motivation over the study period. Conclusion Facilitators prognosticated the anticipated challenges to the successful implementation of simulation-based training on HEMS bases and suggested solutions for overcoming these challenges. After one year of simulation-based training, the facilitators reflected on the key factors for successful implementation.